Genitourinary injuries are identified acutely in less than 5% of patients sustaining pelvic fractures [1]. However, 31-67% of women and 14-72% of men report sexual dysfunction after blunt pelvic ring injury [2], [3], [4], [5]. The pathophysiology of sexual dysfunction after pelvic ring injury may be multifactorial, with contributions from neurologic and vascular trauma, symptomatic mechanical skeletal instability or deformity, and psychological components [6]. Little is known about the possible contribution of iatrogenic surgical insult of skeletal stabilization of the pelvic ring to sexual dysfunction reported by patients with these injuries. Anatomic risk to external genital structures is particularly relevant to percutaneous internal fixation of the anterior pelvic ring.

Retrograde intramedullary fixation of the superior pubic ramus is a minimally invasive method of stabilizing fractures of the anterior pelvic ring and anterior column of the acetabulum, with reported efficacy of 84-90% fracture union and 7-13% reoperation [7], [8], [9]. Safe intraosseous implant placement in the superior pubic ramus avoids articular penetration of the femoroacetabular joint and cortical penetration in the region of the femoral vessels [10]. Initially described for 3.5 mm and 4.5 mm implants, [7] the intraosseous pathway may accommodate 7.3 mm diameter or greater implants in some patients [11].

Cadaveric series simulating retrograde percutaneous superior pubic ramus screw insertion over a guidewire have identified potential injury to the spermatic cord and corpus cavernosum in males as well as glans clitoris and clitoral body in females [12,13]. However, the proximity of instrumentation to genital structures has not been evaluated in living adults. The purpose of this investigation was to quantify the risk of iatrogenic injury to genital structures during simulated placement of retrograde intramedullary fixation of the superior pubic ramus/anterior column using computed tomography (CT) scans obtained in living adults. We hypothesized that simulated screw diameter would be associated with simulated injury to male and female genital structures associated with the anterior pubis if measures are not taken during surgery to protect these structures.