Penetrating trauma to the external genitalia in Operation Iraqi Freedom

Urologic Trauma Management for Military Providers

INTRODUCTION

Genitourinary (GU) trauma resulting from combat and the treatment of these injuries is an inadequately explored subject. While historically accounting for 2 to 5% of combat-related injuries, GU-related injuries escalated considerably during U.S. involvements in Iraq and Afghanistan due to improvised explosive devices (IEDs). Advanced body armor increased survivability while altering injury patterns, with a shift toward bladder and external genitalia injuries. Forward-deployed surgeons and military medics manage treatment, with Role 2 facilities addressing damage control resuscitation and surgery, including GU-specific procedures. The review aims to provide an overview of GU trauma and enhance medical readiness for battlefield scenarios.

MATERIALS AND METHODS

This review examined urologic trauma management in combat, searching PubMed, Cochrane Central, Scopus, and Web of Science databases with search terms "wounds" OR "injuries" OR "hemorrhage" AND "trauma" AND "penile" OR "genital" AND "combat." Records were then screened for inclusion of combat-related urologic trauma in conflicts after 2001 and which were English-based publications. No limits based on year of publication, study design, or additional patient-specific demographics were implemented in this review.

RESULTS

Ultimately, 33 articles that met the inclusion criteria were included. Included texts were narrowed to focus on the management of renal injuries, ureteral trauma, bladder injuries, penile amputations, urethral injuries, testicular trauma, Central nervous system (CNS) injuries, and female GU injuries.

CONCLUSIONS

In modern conflicts, treatment of GU trauma at the point of injury should be secondary to Advanced Trauma Life Support (ATLS) care in addition to competing non-medical priorities. This review highlights the increasing severity of GU trauma due to explosive use, especially dismounted IEDs. Concealed morbidity and fertility issues underscore the importance of protection measures. Military medics play a crucial role in evaluating and managing GU injuries. Adherence to tactical guidelines and trained personnel is vital for effective management, and GU trauma's integration into broader polytrauma care is essential. Adequate preparation should address challenges for deploying health care providers, prioritizing lifesaving and quality-of-life care for casualties affected by GU injuries.

Male genital trauma caused by self-mutilation: A first case series report in Indonesia

INTRODUCTION AND IMPORTANCE

Genital self-mutilation (GSM) is a rare phenomenon with a spectrum ranging from a superficial laceration to complete amputation of the external genitalia. These could result in severe impairment of genitourinary functions. Psychotic disorder adds to the complexity of the patients. Since GSM is underreported, we report the first case series in Indonesia.

CASE PRESENTATION

Four included patients comprised different injuries to the external genitalia, from a superficial laceration to penile amputation. Notably, these patients exhibited psychotic traits. Initial management consisted of bleeding control, debridement, and primary suturing. Depending on the extent of the injury, the repair comprised of spermatic cord ligation, penile reconstruction using a skin flap, defect closure with urethral spatulation, and exploration. We successfully managed all the patients surgically before undergoing psychotherapy to improve the patient's overall well-being and to reduce the risk of similar reoccurrence of GSM behavior.

CLINICAL DISCUSSION

The majority of GSM cases were associated with psychotic disorders. The current reports' injuries include penile laceration, total penile amputation, unilateral castration, and combined injury to the penis and scrotum. Although most GSM is not life-threatening, it may cause emergent, complex, and serious complications such as massive hemorrhage and severe infections. Appropriate investigations with systematic treatment strategies are required, especially in complex cases.

CONCLUSION

The incidence of genital self-mutilation necessitates a prompt evaluation of organ viability and the possibility of preserving tissue for optimal urinary and sexual outcomes. Interdisciplinary collaboration is required as the primary concern for management in cases of genital self-mutilation involving male genitalia and underlying psychological disorders.

Male Genitourinary Injuries in Combat - A Review of United States and British Forces in Afghanistan and Iraq: 2001-2013

As we look to the current conflict in Ukraine, our service members deploy to periphery Northern Atlantic Treaty Organization countries. At the same time, we see an increase in high-kinetic wounding patterns in the United States. We look to the important underrepresented topic of urologic trauma in combat casualties to prepare for the wounds of modern warfare. Genitourinary wounds are increasingly frequent and affect both military and civilian casualties; civilian urologists and deployed surgeons require proficiency in treating these wounds. We present this review of urologic trauma in Afghanistan and Iraq to inform considerations for urologic surgeons and first responders.

Penetrating Scrotal Injuries: A War Time Experience in a Civilian Setup

AIM: To present our experience in managing testicular involvement in penetrating scrotal injuries, trying to highlight a possible role for conservative management of selected cases. METHODS: We reviewed retrospectively all-penetrating scrotal injuries presented to Alyarmook teaching hospital for the period between January 2009 and November 2015, including only those injured victims who reached the hospital alive. Patients’ charts reviewed regarding their demographic data including age, status being civilian or military, and married or single. We documented as well the cause of injury (bullets vs. explosive devices), laterality, associated injured organs, and type of management performed whether operative or non-operative conservative approach. Postoperative complications were recorded while in-patient and after a follow-up period of at least 1 month. RESULTS: Thirty-one penetrating scrotal injuries were identified, resulted in 34 injured testicles. The patients’ mean age was 34.35 years (±12.89standard deviation [SD]) (18–70 years). Most of the victims 24 (77.4%) were civilians. Explosive devices were the cause of injury in 23 patients (74.2%), while bullets were the cause in the remaining 8 patients (25.8%). Orchidectomy needed to be done in 17 (50%) testicles, while 11 (32.4%) injured testes were repaired by suturing. Six cases (17.6%) were treated conservatively without any surgical intervention. The overall testicular salvage rate was (50%). Twenty-one patients (68%) had associated injuries, mostly fractures. Complications occurred in 10 (32.2%) patients, including two mortalities. CONCLUSIONS: Management of genitourinary injuries continues to be a challenging task. In our penetrating testicular injured series, we succeeded to salvage 50% of the injured testes. Non -surgical treatment is feasible in selected patients, an approach that needs further study and longer follow-up.

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Attitudes Toward Penile Transplantation Among Urologists and Health Professionals

Introduction

Penile transplantation, in its infancy, has the potential to reestablish functional outcomes for men with penile loss and disfigurement. However, significant bioethical considerations are pertinent, and systematic discussions are necessary to safely progress implementation.

Aim

To determine the attitude of health practitioners toward the penile transplant and identify the key aspects of concern pertinent to the operation and clinical care.

Methods

Health care professionals from the United States responded to either email invitation, web link, or social media post on Facebook to complete a questionnaire investigating perceptions and attitudes toward penile transplantation.

Main Outcome Measures

Respondents' attitude toward penile transplantation, their own perceived important functions of the penis, and concerns about performing a penile transplantation. Respondents' previous exposure to visceral transplants, to penile disfigurement, and information about penile transplants were used as independent factors in analysis.

Results

Among 412 health care professionals who responded to the questionnaire, 95.9% were in favor of visceral organ transplant, but only 64.3% were in favor of penile transplantation. The results showed that 61.3% of respondents first learned about the penile transplant from mass media, whereas only 37.5% had been exposed through a scientific journal, formal lecture, or a professional colleague. Younger health professionals and those exposed through professional forums surrounding penile transplantation were more likely to be in favor of the procedure (P < .001). The most important functions of the penis were identified by respondents as being sexual function (role in sexual activity) and gender identity (being a man) with rates of 86.4% and 85.3%, respectively (P < .001). Barriers identified by respondents included the use of immunosuppression and the potential subsequent effect on healthcare resource utilization. Reading an excerpt about penile trauma in war during the questionnaire improved acceptance of penile transplantation (P = .05).

Conclusion

Penile transplantation is accepted by most health professionals surveyed. Younger respondents and those informed through professional outlets are more favorable toward penile transplantation. Anticipated limitations include the risk of immunosuppression, lack of available donors, and the effect on healthcare utilization.

Najari B, Flannigan R, Hobgood J, et al. Attitudes Toward Penile Transplantation Among Urologists and Health Professionals. Sex Med 2018;6:316–323.

War-related penile injuries in Libya: Single-institution experience

Objective

To report on our initial experience in the management of war-related penile injuries; proper diagnosis and immediate treatment of penile injuries is essential to gain satisfactory results. Besides treating primary wounds and restoring penile function, the cosmetic result is also an important issue for the surgeon.

Patients and methods

The study was conducted in the Department of Urology at Benghazi Medical Center and comprised all patients who presented with a shotgun, gunshot or explosive penile injury between February 2011 and August 2017. The patient’s age, cause of injury, site and severity of injuries, management, postoperative complications, and hospital stay, were recorded.

Results

In all, 29 males with war-related penile injuries were enrolled in the study. The mean (SD) age of these patients was 31.3 (10.5) years. The glans, urethra, and corporal bodies were involved in four (13.7%), 10 (34.4%), and 20 (68.9%) of the patients, respectively. According to the American Association for the Surgery of Trauma Penis Injury Scale, Grade III penile injuries were the most common (11 patients, 37.9%). The most common post-intervention complications were urethral stricture with or without proximal urethrocutaneous fistula (eight patients, 27.5%), followed by permanent erectile dysfunction (five patients, 17.2%).

Conclusion

In patients who sustain war-related penile injuries the surgeon’s efforts should not only be directed to restoring normal voiding and erectile function but also on the cosmetic appearance of the penis.

Improvised explosive device-related lower genitourinary trauma in current overseas combat operations

BACKGROUND

The use of improvised explosive devices (IEDs) has had a profound effect on battlefield trauma in the 21st century. Historically, wounds to the genitourinary (GU) structures have been less common than extremity and penetrating abdominal trauma in combat operations. GU injury incidence, severity, and associated injuries secondary to the use of this weapon in Operations Iraqi and Enduring Freedom has not been described.

METHODS

Data from the Department of Defense Trauma Registry was reviewed for combat-related GU injuries in Operations Iraqi and Enduring Freedom from 2001 to 2011. All wounded US armed service members are included in this database. Subjects were selected by a query of current procedural terminology and DRG International Classification of Diseases-9th Rev. codes related to traumatic injury of the penis, scrotum, testicles, and urethra. A retrospective chart review was performed for each patient to identify the date of injury, the mechanism of injury, and the associated traumatic wounds. Subjects' follow-up records were reviewed until present time or separation from active duty.

RESULTS

A total of 501 soldiers sustained lower GU trauma, with a total of 729 injuries. Of these casualties, 448 (89%) were wounded by IEDs. Dismounted injuries (87%) made up more of the cohort than did vehicular. Specific trauma sites include 149 (20%) penile, 260 (36%) testicular, 284 (39%) scrotal, and 36 (5%) urethral injuries. The 180 limb amputations (36%) and 86 fractures (17%) were the most encountered concomitant skeletal wounds among service members with GU injuries.

CONCLUSION

This is the first review of all lower GU trauma sustained by all US armed service members in current overseas combat operations. Combat-related lower GU trauma is primarily caused by IEDs in the spectrum of complex dismounted blast injuries. The mechanism primarily results in multisystem injury, with isolated GU involvement being uncommon. Continued evaluation of long-term sequelae, including sexual, urinary, and reproductive dysfunction, is needed.

LEVEL OF EVIDENCE

Epidemiologic study, level V.

Effectiveness of the combat pelvic protection system in the prevention of genital and urinary tract injuries: An observational study

BACKGROUND

Historically, the incidence of genital and urinary tract (GU) injuries in major conflicts has been approximately 5%. To mitigate the risk of blast injury to the external genitalia, the United States and United Kingdom issued protective overgarments and undergarments to troops deployed in support of Operation Enduring Freedom. These two systems combined constitute the pelvic protection system (PPS). Our hypothesis was that PPS use is associated with a reduction of GU injuries in subjects exposed to dismounted improvised explosive device blast injuries.

METHODS

We identified two groups for comparison: those who were confirmed to have worn the PPS at time of injury (n = 58) and a historical control group who were confirmed as not wearing the PPS (non-PPS) (n = 61). Patients with any level of lower extremity amputation from dismounted improvised explosive device blast mechanism were included. The primary outcome measure was presence of a GU injury on admission. A univariate analysis assessing the strength of association with odds ratios and 95% confidence intervals was performed between the PPS and non-PPS groups.

RESULTS

Mean Injury Severity Score (ISS) was higher in the PPS versus the non-PPS group (26.1 vs. 19.3, p = 0.0012). Overall, 31% of the patients in the PPS group sustained at least one GU injury versus 62.3% in the non-PPS group. The odds ratio of sustaining a GU injury in the PPS group as compared with the PPS group is 0.28 (31% vs. 62.3%; 95 % confidence interval, 0.62-0.12; p < 0.001). The most frequent injures were open scrotal/testes wounds, followed by open penis, and open bladder/urethra injuries.

CONCLUSION

The use of the PPS is associated with a decreased odds ratio of GU injury. Despite a 31% absolute reduction, future work should focus on improved efficiency.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Testosterone recovery after polytrauma and scrotal injury in patients from Operation Enduring Freedom and Operation Iraqi Freedom

PURPOSE

We examined the long-term natural history of testosterone recovery in patients with complex battle injuries.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients who participated in Operation Enduring Freedom and Operation Iraqi Freedom, and underwent urological surgical consultation at Walter Reed Army Medical Center, Washington, D.C. or the National Naval Medical Center, Bethesda, Maryland, from 2001 to August 2011. Of the 192 patient charts reviewed 138 (72%) had testosterone values available. The study inclusion criterion of at least 2 testosterone measurements, including 1 made within 40 days of injury, was met by 84 patients (61%) with testosterone data available. Those treated with bilateral orchiectomy were not required to meet this criterion.

RESULTS

Initial patient testosterone after injury in the testosterone recovery group was inversely proportional to the degree of scrotal injury. In patients in whom testosterone recovered to at least 250 ng/dl the recovery occurred a mean of 4.5 months after injury. Patients who required testosterone replacement had lower initial testosterone (p = 0.0063) and lower testosterone velocity (p <0.0001).

CONCLUSIONS

Monitoring the velocity of testosterone recovery is a viable approach in male patients who receive significant genitourinary trauma. In patients in whom testosterone recovered the recovery occurred within a mean of 5 months after injury. It is reasonable to observe patients with scrotal injuries since testosterone may recover in many of them without intervention.

Lower genitourinary trauma in modern warfare: the experience from civil violence in Iraq

BACKGROUND

Reports on genitourinary (GU) trauma during the Iraqi conflict have been limited to battlefield injuries. We sought to characterise the incidence, mechanism of injury, wounding pattern, and management of lower GU injuries sustained in civil violence during the Iraqi war.

PATIENTS AND METHODS

A total of 2800 casualties with penetrating trauma to the abdomen and pelvis were treated at the Yarmouk Hospital, Baghdad from January 2004 to June 2008. Of the casualties 504 (18%) had GU trauma including 217 (43%) with one or more injuries to the lower GU organs.

RESULTS

Among the 217 patients there were 262 lower GU injuries involving the bladder in 128 (48.8%) patients, bulbo-prostatic urethra in 21 (8%), penis in 24 (9.2%), and scrotum in 89 (34%). Injuries to the anterior urethra and genitals were inflicted by Improvised Explosive Devices (IEDs) in 53-67% of cases and by individual firearms in 33-47%, while injuries to the posterior urethra and bladder were inflicted by IEDs in 17-22% of cases and by firearms in 78-83%. All penile wounds were repaired save 3 (12.5%) patients who underwent total penectomy. Of 63 injured testicles 54 (86%) could be salvaged and 9 (14%) required unilateral orchiectomy. The leading cause of death was an associated injury to major blood vessels in 26 (84%) of 31 patients who died.

CONCLUSIONS

Injuries to the anterior urethra and genitals were commonly caused by IEDs, while injuries to the posterior urethra and bladder were usually caused by individual firearms. Testis injury was almost always salvageable. Associated trauma to major blood vessels was the leading cause of death in these casualties.

Battlefield scrotal trauma: how should it be managed in a deployed military hospital?

AIM

There is little documented advice on the management of scrotal trauma sustained in combat. This paper reviews this injury, its present surgical management and makes recommendations for the future.

METHOD

All UK forces sustaining scrotal injuries between 2003 and 2009, in Iraq and Afghanistan, initially treated at a Role 2 (enhanced) or Role 3 deployed military surgical facility were identified from the Joint Theatre Trauma Registry. The cause and extent of the injury, in addition to the surgical management, are reported.

RESULTS

Twenty-seven patients sustained trauma to their scrotum; improvised explosive device (IED) (n=21), mine (n=3), rocket propeller grenade (RPG) (n=2), mortar round (n=1). Of those injured by an IED, eleven had traumatic orchidectomies, of which 4 were bilateral, one received fragmentation wounds to the scrotum with a testicular injury that was salvaged and there were six scrotal fragmentation wounds not associated with a testicular injury. Scrotal exploration was performed with testicular salvage in all cases involving mortar, RPG or mines. For all aetiologies the scrotum was debrided with primary closure over a drain (n=7), debridement and subsequent delayed primary closure (DPC) (n=4) or healing by secondary intension (n=6). Skin grafts were applied in two cases of traumatic bilateral orchidectomy. To date there have been two cases of delayed orchidectomy; chronic pain and delayed presentation of a disrupted testis. All reported patients survived.

CONCLUSION

The established principles of debridement should be the mainstay of treatment. Testicular ischaemia, a consequence of cord transaction, necessitates orchidectomy. Salvage of the disrupted testis, with debridement and closure of the tunica rather than orchidectomy, should be performed whenever possible, particularly when there is significant bilateral testicular injury. Scrotal wounds can be treated by closure over a drain, DPC or healing by secondary intention.

Management of combat-related urological trauma in the modern era

Complex genitourinary injuries--associated with lower-extremity amputation as well as pelvic and abdominal wounding--have emerged as common occurrences in current military combat operations. The nature of combat injuries of the genitourinary tract is varied, as are the strategies used in their management. For example, 5% of all combat injuries include wounds of the urinary system or genitalia. For injuries that are predominantly penetrating in nature, immediate care requires the judicious preservation of viable tissue. Once the patient is stable, urethral, corporal and testicular lacerations are closed primarily, whereas soft tissue injuries are re-approximated in a delayed fashion. Negative-pressure dressings have been a useful aid in wound management; wound coverage is most commonly completed with split-thickness skin grafts and local flaps. Complex penile and urethral reconstructions are often delayed so orthopaedic injuries can heal and the patient can manage activities of daily living. Final reconstruction requires a urologist with a full understanding of reconstructive techniques.

Clinical characteristics and surgical outcomes of penetrating external genital injuries

BACKGROUND

Penetrating external genital injuries, although uncommon, may present complex problems for the urologic and trauma surgeon. A paucity of data exists on the incidence, clinical characteristics, and management outcomes of these injuries because few institutions have the volume to report their experience.

METHODS

Penetrating external genital trauma presenting from 2004 to 2011 was retrospectively reviewed. Patient characteristics, operative and nonoperative management, and outcomes were analyzed while validating current guidelines. Surgical management is described in detail, and overall incidence and trends were calculated.

RESULTS

A total of 28,459 trauma patients were reviewed, of which 8,076 sustained penetrating injuries and 162 sustained penetrating external genital trauma. Penetrating external genital trauma was 0.57% of all trauma and 2.0% among penetrating trauma. Gunshot wounds accounted for the most common mechanism of injury (93%). Injury to the scrotum occurred in 78% and of these injuries, 63% resulted in a testicular injury, with bilateral testicular injuries occurring in 8%. Testicular reconstruction was performed in 65%. Penile injuries occurred in 28%, and urethral injuries occurred in 13%. For penile injuries, 62% were explored immediately. Urethral injuries were managed by immediate primary urethral repair (43%) or urinary diversion with delayed reconstruction (57%). In total, nonoperative management was performed in 26% of scrotal and 38% of penile injuries. The incidence of penetrating external genital injuries has remained constant during our study period, averaging 20.2 cases per year (R(2) = 0.99). The testicular salvage rate varied from 55% to 75% per year (R(2) = 0.06).

CONCLUSION

Penetrating external genital injuries occur at an incidence of 0.57% where scrotal injury from gunshot wounds is the most common form. Testicular preservation is possible in the majority of testicular injuries. Penile injuries were less likely to require surgical exploration compared with scrotal injuries likely because physical examination is better at confirming only superficial injury. Select patients with superficial scrotal or penile injuries may undergo nonoperative management with minimal morbidity.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemiologic study, level IV.

Current epidemiology of genitourinary trauma

This article reviews recent publications evaluating the current epidemiology of urologic trauma. The authors briefly explain databases that have been recently used to study this patient population and then discuss each genitourinary organ individually, utilizing the most relevant and up-to-date information published for each one. The conclusion of the article briefly discusses possible future research and development areas pertaining to the topic.

Changes in surgical workload at the JF Med Gp Role 3 Hospital, Camp Bastion, Afghanistan, November 2008-November 2010

INTRODUCTION

The operative workload at the surgical facility in Camp Bastion, Afghanistan, has previously been reported for the two-year period 1 May 2006 to 1 May 2008. There have since been considerable changes not only in the casualty rates, but also in the injury patterns encountered. Severe wounds from improvised explosive devices (IEDs) have become the signature injury of the insurgency. We present recent data for the surgical activity at the Joint Forces Medical Group Role 3 Hospital, Camp Bastion, for the two-year period 1 November 2008 to 1 November 2010.

PATIENTS AND METHODS

A retrospective analysis of the operating theatre logbooks was undertaken for the period 1 November, 2008 to 1 November, 2010.

RESULTS

During the study period a total of 4276 cases required 5737 surgical procedures. Compared with the previously reported series from May 2006 to 2008, this represents a 2.6-fold increase in the surgical workload of the hospital. There has been a 5.7-fold increase in the number of amputations (483 during this study period, 8.4% all operative procedures), and for the lower limbs these have become increasingly proximal (48% all amputations were above-knee lower limb amputations). During the study period there were also significant increases in the frequency of perineal injuries as well as the numbers of cases involving 5 or more surgeons.

DISCUSSION

The surgical workload at the Role 3 Hospital, Camp Bastion, Afghanistan is increasing. This is a result not only of increasing casualty numbers but also of increasingly severe injury patterns. With the growing use of powerful IEDs, traumatic lower limb amputations in particular are becoming more common, and are increasingly associated with significant pelvic and perineal injury. These complex injury patterns necessitate a multi-surgeon approach, and it is important these trends are noted for future planning of medical support to military operations in Afghanistan.

Combat urologic trauma in US military overseas contingency operations

BACKGROUND

This article reports on the occurrences and patterns of genitourinary (GU) trauma in the contemporary high-intensity conflict of the overseas contingency operations (OCOs).

METHODS

The Joint Theater Trauma Registry was queried for all US military members who received treatment for GU wounds and concomitant injuries sustained in OCOs for >75 months between October 2001 and January 2008.

RESULTS

Of the 16,323 trauma admissions annotated in the Joint Theater Trauma Registry, 819 (5%) had one or more GU injuries. Of the GU casualties, 90% were sustained in Iraq and 65% were because of explosions. The average casualty age was 26 years (range, 18-58 years) and 98.5% were men. There were 887 unique GU injuries distributed as follows: scrotum, 257 (29.0%); kidney, 203 (22.9%); bladder, 189 (21.3%); penis, 126 (14.2%); testicle, 81 (9.1%); ureter, 24 (2.7%); and urethra, 7 (0.8%). Of the 203 patients with kidney injuries, 22% went to the operating room with 31 patients having nephrectomies. There were 189 bladder injuries with 26 patients (14%) having concomitant pelvic fractures.

CONCLUSIONS

This is the largest report of GU injuries during any military conflict. The distribution and percentage of casualties with GU injuries in the OCO are similar to those of previous conflicts. Consideration should be given to personnel protective equipment for the areas associated with GU injuries and predeployment training directed at the care of these injuries.