Urotrauma: A Pelvic Floor Therapy Approach to Military Trauma

Mary McVearry, PT, DPT, WCS

Carina Siracusa Majzun, PT, DPT

Combined Sections Meeting, February 5, 2015

• Historically, Genitourinary (GU) injury was a minor battlefield trauma
• Aggressive use of Improvised Explosive Devices (IEDs) has resulted in frequent combination of:

o   Lower extremity amputation

o   Pelvic injury/fracture

o   Abdominal injury

o   Urogenital injury

o   Termed “dismounted complex battle injury” by a US Army task force

o   This is a new injury of the past 5-10 years; soldiers did not survive previously

• Increased Severity & Decreased Mortality
• Military medical operations have prioritized bringing surgical resources far forward on the battlefield

§  Soldiers have survived more catastrophic injuries

§  Wound debridement is a key in initial management

§  Delayed reconstruction

• Very limited long-term data on

§  Urinary function

§  Sexual function

§  Fertility

§  Psychological effects

§  Emotional effects

·         Common Genitourinary Trauma

o   Bladder

o   Penile

o   Testicular

o   Perineal

o   To includes pelvic floor

o   Anorectal

o   Ureteral*

o   Renal*

•       Anal sphincter injury mainly due to blast injury

–      Possible sphincteroplasty if enough viable tissue

–      Extensive muscle loss and tissue damage

–      Scarring and anal stenosis

–      Heterotopic Ossification (bone formation)

•       Isolated rectal injury not as common

–      Protection by

•       Bony confines of sacrum and coccyx

•       Gluteal musculature

•       Perineal injury management

–      Primary aim = healing from acute trauma

–      Secondary aim = restoration of sphincter function to allow for continence

•       Common practice:

–      Diverting colostomy

–      Suprapubic urinary drainage

–      Allows for perineal tissue/sphincter healing and reduces risk of local and systemic infections

•       Medevac Transport and Uprange Definitive Care within 48-72 hrs (out of combat theater to Landstuhl Regional Med. Ctr in Germany to Walter Reed or Brooke in USA)

•       Team Approach Treatment

•       Patients are living on base

•       Job is rehabilitation, planning for upcoming surgeries

•       Case manager for each wounded warrior

•       monitors progress

•       coordinates care

•       schedules appointments

•       Followed by several services

•       General surgery

•       Colo-rectal

•       Urology

•       Pain management

•       Orthopedics

•       Physical Medicine

•       Behavioral Health

•       Physical Therapy

•       Occupational Therapy

•       Presentation to Pelvic Floor PT

•       Typically 6-9 months following initial injury

•       Medically stable

•       In daily PT/OT

•       Mobility level:

•       Independent with all wheelchair mobility

•       Independent with transfers

•       May/may not be using prostheses for ambulation

•       Case #1- 33 yo male enlisted Army soldier, married, 1 yo dtr.

•       Referred by Urology for eval and rx of reduced sensation of bladder filling and inability to spontaneously void

•       6 mos. s/p IED injury

•       B transfemoral amputation- Indep. Wc mob, just starting prosthetic training

•       Bladder neck damage

•       Pelvic fx, SP separation, SIJ diastasis w/ screw fixation

•       TBI

•       Colostomy

•       Suprapubic catheter (SPC)- no urethral restrictions

•       Symptoms:

•       Minimal urge to urinate

•       Inability to void indep despite clamping the SPC

•       Small amount of rectal seepage

•       UI with transfers, cough, sneeze

•       ED

•       Exam:

•       Significant perineal and sacral scarring

•       Decreased sensation to light and sharp touch left S2-5 dermatomes (intact on right)

•       Erythema rectal mucosa with granulation tissue presentà no rectal exam due to tissue still healing

•       PFM activity assessed with sEMG at EAS

•       Overuse of gluts

•       Low resting and contract activity (scarring impairing readings?)

•       Intervention

•       sEMG biofeedback

•       PFM training

•       Neuromodulation with TENS

•       Sacral modulation contraindicated due to metal screw

•       PTNS not an option due to amputation

•       Applied suprapubically- 2 electrodes 1.5 inches apart

•       Low freq: 10 htz, burst mode

•       Outcome:

•       Post 4 weeks daily x one hourà able to spont void and empty bladder with SPC clamped 3-4x/day

•       Post 6 weeksà bladder capacity increased from 300 ml to 500 ml), no PVR, SPC removed, TENS d/c’d

•       F/U at 12 weeksà spont void maintained, resolution of UI and rectal seepage, grad return of erectile function

•       Take home points:

•       Results will vary depending on degree of damage and viable tissue left for repairs

•       Constantly re-evaluate, monitor progress, communicate with team

•       Think outside the boxà there are no protocols or research

•       Physical damage may be accompanied by PTSD, TBI, significant psychological comorbidity due to injuries occurring during male’s peak reproductive and sexual years, and perceived “loss of masculinity”, loss of body image 

Female Genital Mutilation

·         Female genital cutting (FGC) is the partial or total removal of a girl’s external genitals. Her body is physically damaged when the healthy tissue of her genitals are cut away. There are no health benefits to FGC.

·         Complex cultural and social reasons are often given about why it is practiced.

·         FGC has harmful effects on the health and wellbeing of a woman throughout her life and contravenes human, women’s and child rights. Female genital cutting is also commonly referred to as female genital mutilation (FGM).

·         Female genital cutting is a social norm. This means that it is held in place by the entire community. One individual acting alone cannot shift a social norm – the entire community must work together collectively.

·         Men and women often support FGC without question because it is a traditional practice that has existed in a community for generations. Many communities believe that a girl needs to be cut in order to marry well.

·         Despite the fact that it is harmful to women, FGC is sometimes seen as an issue that women confer onto other girls. Even if a mother does not want her daughter to be cut because of her own painful experience, or parents know the health risks associated, they are unlikely to forego the practice because of the social sanctions in place.

·         Parents cut their daughters because they believe that this will allow her to be accepted into society. A girl who is uncut is often seen as dirty and can be ostracized. In some instances, an uncut woman may not be allowed to cook food or eat out of the communal bowl – she is excluded from her community. Most parents believe that having their daughter cut will help her by saving her from social exclusion, improving her marriage prospects. 

·         In some communities, a girl who is not cut is seen as unclean and sexually promiscuous. On the other hand, the belief is that a girl who is cut will make a good marriage because she is thought to be cleaner, more fertile and will be a virgin until her wedding night. When a woman is sealed closed after being cut, people think that it means that she will not have intercourse until she is married. Another issue can be a lack of understanding that desire is psychological rather than physical.

·         Others believe that female genitals are unclean and that an infant can die during birth by coming into contact with the mother’s clitoris. To many, being cut is synonymous with being healthy, chaste and beautiful. There are many superstitions around the practice. For example, it is sometimes believed that if a girl is not cut, her clitoris or labia will grow to unseemly, masculine proportions.

·         Today, many will also cite religion as a reason for FGC. But FGC is not prescribed by any of the major religions. The practice is thought to have originated around 2,200 BC, before the advent of Islam and Christianity. FGC can be practiced by Christians, Muslims, Jews and atheists alike.