Screening and referral for pelvic floor dysfunction after pelvic fracture: when is it needed?

To ascertain the prevalence and severity of PFD in adults three- and 12-months post-pelvic fracture; and determine the feasibility of a new screening process at three-months post-pelvic fracture with respect to referral uptake to pelvic floor physiotherapy services. 

Multi-site observational and nested randomised control trial (RCT). Adults sustaining ≥1 pelvic fracture were recruited from two major trauma hospitals. Preceding hospital discharge, a demographics questionnaire, the Australian Pelvic Floor Questionnaire (APFQ) and simplified International Index of Erectile Function (IIEF-5, males only) were completed as baseline pelvic floor function via online survey (REDCap). Instruments were repeated at three- and 12-months. Participants scoring an increase of ≥1 on the APFQ or ≤21 on the IIEF-5 at three-months were enrolled in the RCT as they were deemed to have developed PFD since pelvic injury. The intervention group were offered referral for pelvic floor physiotherapy and the control group received standard care (with referral at 12 months if symptoms ongoing). Data were analysed descriptively (SPSS V28). 

Between November 2022 - August 2024, 428/1009 patients screened (61% male) were excluded (main exclusion isolated acetabular fracture 35%). Of the 391 enrolled in the observational study (consent rate 67%), mean (SD) age was 51.2 (18.7) years, 63% were males, 59% received non-operative management for pelvic fracture and 78% sustained concurrent injuries. At three-months, 67% had never been asked by a clinician about PFD and 90% never offered treatment. Prevalence in males of new PFD following pelvic trauma was 60% (median [IQR] APFQ 7.0 [2.0-12.0]; IIEF-5 20.0 [9.0-24.0], n=180). For females, the prevalence of new PFD was 72% (median [IQR] APFQ 12.0 [6.0-24.8], n=112). Of the 96 randomised to the intervention 40 declined referral; 68% of these outright declined, while 23% did not prioritise PFD treatment amongst current physical impairments. Of the 12-month follow-ups completed (male= 92, female= 49), the prevalence of ongoing PFD is 53%. From the 41 participants with a PFD that had not been previously offered referral, 44% have accepted referral. 

A new PFD post-injury was found in 60% of males and 72% of females. Largely, these participants were not screened for PFD by other clinicians nor received any treatment. There is clearly a need for screening and awareness of PFD in the pelvic trauma population. However, addressing PFD within the first-year post-injury might be a low priority for people with multi-trauma. Physiotherapists could include education about PFD throughout recovery, formally screen for symptoms during rehabilitation and provide fist line education and specialist referral when needed.  

Physiotherapists who treat patients with pelvic fracture need to be aware of the likelihood of PFD in the pelvic fracture population and consider screening for PFD as part of their acute and sub-acute rehabilitation.