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

Clinical management of active bleeding: what the emergency radiologist needs to know

Active bleeding is a clinical emergency that often requires swift action driven by efficient communication. Extravasation of intravenous (IV) contrast on computed tomography (CT) is a hallmark of active hemorrhage. This can be seen on exams performed for a variety of indications and can occur anywhere in the body. As both traumatic and non-traumatic etiologies of significant blood loss are clinical emergencies, exams demonstrating active bleeding are often performed in emergency departments and read by emergency radiologists. Prompt communication of these findings to the appropriate emergency medicine and surgical providers is crucial. Although many types of active hemorrhage can be managed by interventional radiology techniques, endoscopic and surgical management or clinical observation may be appropriate in certain cases. To facilitate optimal care, it is important for emergency radiologists to understand the scope of indications for embolization of bleeding by interventional radiologists (IR) and when an IR consultation is warranted. Similarly, timely comprehensive diagnostic radiology reporting including pertinent positive and negative findings tailored for IR colleagues can expedite the appropriate intervention.

Gunshot wound injury to the genitourinary tract: a 4-year retrospective review at an academic level 1 trauma center

Background

Firearm injuries increased significantly during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to describe our experience with patients admitted to a level 1 trauma center with gunshot-related trauma to the genitourinary (GU) tract before and during COVID-19 pandemic.

Methods

Patients sustaining gunshot-related trauma to the adrenals, kidneys, ureters, bladder, scrotum, testicles, penis, and urethra between January 1, 2018 and December 31, 2021 were identified from our institutional trauma database. Patient charts were queried to extract demographic information, management, and follow-up.

Results

A total of 117 patients met inclusion criteria with 39 (33%) of GU injuries occurring pre-COVID, and 78 (67%) occurring during or post-COVID. Seventy-two (62%) presented with kidney injury. Patients injured in the pre-COVID period were more likely to participate in a follow-up visit by 2.17 times at 60 days (P=0.017), 1.98 times at 90 days (P=0.030), and 2.04 times at 1-year (P=0.014) than during COVID. Pre-COVID, 46% of patients were injured in the city's northwestern region and 54% from other areas, during COVID 24% of patients came from the northwestern region compared to 76% from other areas (P=0.029).

Conclusions

Gunshot wounds (GSW) involving the GU tract increased during the COVID-19 pandemic, with renal injury most frequent. Follow-up visits declined by around half during the pandemic, primarily at 60 days, 90 days, and 1 year post-injury. The number of patients admitted with urologic injuries pre-COVID versus during COVID was significantly different depending on the patient's area of residence. More work is needed to evaluate the outcomes of traumatic GU injuries due to GSW pre- and post-pandemic.

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

Renal injuries in conflict zones: a 6-year study of traumatic cases in Afghanistan

PURPOSE

During hostilities, gunshot wounds are the most common cause of penetrating injuries. In 8-10% of abdominal injuries kidneys are involved. The treatment method include surgical or conservative treatment (fluids + blood components).

METHODS

Of 1266 combat trauma cases treated during 6 to 14 rotation of the Polish Military Contingent in Afghanistan, we extracted a subgroup of 44 kidney injuries. Corelation of trauma mechanism, PATI score, treatment methods, and outcomes was evaluated.

RESULTS

Out of the 41 renal injuries, 20 considered left, 18 right, and 3 both kidneys. There were no statistical significancy in injury lateralization (p = 0.669), and no differences regarding side of a trauma and quantity of blood component used for the treatment (p = 0.246). Nephrectomy was performed on 17 patients (13 left vs. 4 right). A significant correlation between PATI score and the need for a nephrectomy (p = 0.027) was confirmed. Penetrating trauma recquired higher number of blood components comparing to blunt trauma (p < 0.001). The renal salvage rate was in study group was 61.36%. The overall survival (OS) rate was 90.25% - 4 patients died due to trauma.

CONCLUSIONS

The damage side does not result in a statistically significant increase in the need for blood transfusions or differences in the PATI score. The mechanism of trauma does, however, affect the number of blood components required for treatment, particularly in cases of penetrating trauma. With the introduction of proper treatment, the overall survival rate exceeds 90%, even when opting for conservative treatment.

Penile Fracture Secondary to Gunshot Injury: A Multidisciplinary Approach and Exceptional Surgical Management in an Uncommon Case

Penile fractures happen when the tunica albuginea is forcefully torn during intense sexual activity or vigorous masturbation. Gunshot-induced cases are extremely rare. Diagnosis, often requiring surgical exploration, poses challenges due to the condition's rarity and severity. We report a complex case of a patient with multiple gunshot wounds, highlighting the need for a multidisciplinary approach for abdominal and genitourinary regions. A 24-year-old male presented to the emergency department with multiple gunshot wounds to the anterior thoracic and abdominal walls, inguinal region, penis, and lower extremities. Despite multiple gunshot wounds, the patient maintained hemodynamic stability during physical examination. No imaging study was performed since surgical management was decided due to the presence of hematemesis. During exploratory laparotomy, a 2 cm stomach lesion was found and repaired by the general surgery team. Urology then addressed genital trauma, identifying and fixing a 1 cm tunica albuginea defect in each corpora cavernosa, achieving bilateral penile fracture repair. The patient was discharged after eight days of hospitalization, with adequate oral intake and urinating. Fifty-two days later, he persists with mild erectile dysfunction (International Index of Erectile Function-5 score: 17 points). This unique case involving a gunshot-induced penile fracture alongside abdominal and several other injuries was successfully managed through a multidisciplinary approach. As these lesions are rare, prompt treatment with standardized surgical procedures for civilian cases is crucial for optimal outcomes.

Air gun accident: A case report of a penile injury

Air rifle, although considered as a toy, can cause injuries ranging from trivial to very grievous. The severity of injuries depends on the type of air rifle, the distance of firing, and the anatomic site at which the bullet hits. We present a case involving a young boy, who was accidently hit by an air rifle while playing. The Bullet penetrated the penis through the glans to be lodged in between the distal extremities of the corpus cavernosum behind the urethra. The surgical treatment was performed and the results were good.

Penetrating gunshot wounds to the penis: a case report of combat patient injured in the war in Ukraine

BACKGROUND

The current war in Ukraine is associated with frequent applications of multiple-launch rocket systems and cruise missiles as well as other various high-energy weapons to cause severe injuries in military personnel including abdomen wounds, vascular injury, and limb amputations as well as genitourinary trauma. The aim of this report is to demonstrate a case of successful penile salvage by restoring its function in a combat patient with gunshot genitourinary trauma in conditions of an interrupted supply of medical equipment.

CASE PRESENTATION

We describe a case of a 48-year-old male patient with a combined shrapnel gunshot wound to the penis with damage to the urethra and combined injury to the soft tissues of the left thigh. Several hours after the injury, the patient underwent primary surgical debridement of the left thigh, ligation of the great saphenous vein of the thigh, primary sutures on the penile urethra and navicular fossa, suturing of the rupture of the head and penis, drainage of the wound, catheterization of the bladder, and epicystostomy. An artificial erection was performed intraoperatively. The urethral catheter was removed 3 weeks after urethral suturing (May 4, 2022). The epicystostomy was removed 5 months after the injury (August 4, 2022) and 2 days after the restoration of spontaneous urination. At the follow-up of 7 months after the injury, the patient has normal urination with minor urinary dribbling, sufficient erection, and ejaculation.

CONCLUSIONS

We have shown that in a case of gunshot wounds to the penis and hanging part of the urethra, even in the presence of combined severe purulent lesions of non-urological localizations, it is possible to perform a primary reconstruction of urogenital injuries using a primary urethral suture and applying a negative pressure device. Findings from this case report shed new light on the management of penile gunshot injury in ongoing warfare as well as provide evidence of the possibility to perform adequate management for penile injury in conditions of limited medical resources, violation of international humanitarian law, and under frequent strikes of high-energy weapons.

Scrotal self-inflicted gunshot injuries: report of two consecutive cases and literature review

Background

Isolated scrotal gunshot injuries are uncommon. Even more so when they are self-inflicted. The extent of the injury is determined by the caliber of the weapon. Established management protocols when followed yields excellent results.

Case presentations

We present two male patients, aged 41 and 51 years old, who sustained gunshot injuries to the scrotum following accidental discharges from hand guns stored in their trouser pockets. The first (41 years) sustained grade 5 American Association for Surgery of Trauma (AAST) left testicular injury and was managed by unilateral orchidectomy. The second (51 years old) sustained bilateral grade 4 AAST testicular injuries and had both testes salvaged by primary repair after meticulous debridement.

Conclusion

Isolated scrotal gunshot injuries can occur when low velocity guns are placed adjacent to the genitalia and accidentally discharged. The testes are endangered and can be devitalized requiring orchidectomy or salvaged by meticulous debridement and primary repair when viability is not compromised.