Our series from the Male Reproductive Health Alliance (MRHA) continues with an article from Steve Waxman, MD, JD. Steve addresses the topic of war and male genital trauma. Steve is a Colonel in the U.S. Army Reserves and deployed to both Iraq and Afghanistan. It's an extraordinarily important article, given the United States' involvement in those wars. The article concludes with an Editorial Comment by Stanton Honig, MD.
With my best regards,
By: Steve Waxman MD, JD
The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
The wars in Iraq and Afghanistan over the past decade have resulted in over 50,000 United States combat related injuries. Genitourinary (GU) trauma accounted for roughly one in twenty of all these injuries. The vast majority of these injuries were puncturing (penetrating) in nature and most were as a result of improvised explosive devices (IEDs). A breakdown of the genito-urinary injuries to the external genitalia was as follows: scrotum in 29%, testis in 9%, and penis in 14%.1 The aftermath of all these injuries from both a physical and mental standpoint are as yet unknown. Blast injuries to the male external genitalia are much different than those injuries seen in civilian practice. Civilian penetrating trauma is typically secondary to gun shot or knife wounds. Blast injuries from IEDs commonly injure the lower extremities in addition to the external genitalia. Typically the wounds are grossly contaminated with debris from the blast. Initial treatment of the wounds depends on the overall severity of the patient's injuries and the concurrent need for damage control resuscitation and surgery.
Saving the testicle(s) in the war zone hospitals have been reported to be as high as 74% in Operation Iraqi Freedom.2 A high index of suspicion is essential when addressing wounds to the external genitalia following an IED blast. Small entry wounds to the scrotum may be associated with severe testicular trauma. There are multiple levels of care in the war zone such that injured patients are systematically evaluated, treated and transported from point of injury up range to larger facilities and eventually out of the war area. At each stop along the chain, patient wounds are examined, washed out, re-explored and repaired if necessary.
The long term effects of blast injuries to the lower urinary tract and external genitalia have not been completely studied as the patients are currently cared for by numerous health care systems around the world in addition to military and Veterans' Administration hospitals. Important information to know would be the number of injured male soldiers with low testosterone, impotence and infertility just to name a few. Also, we must know what additional surgeries were performed to reconstruct these patients. The Army Dismounted Complex Blast Injury (DCBI) Task Force published a report describing the nature, incidence and management of these injuries.3 By definition, this pattern of wounds involve the traumatic amputation of one leg with severe injury to another extremity and pelvic, abdominal or urogenital wounding. As the GU injuries tend to be extensive, the presence of an urologist in theater is crucial. The Army DCBI task force is an excellent start towards improving care for these patients. A new task force on urotrauma has been introduced several times in the United States Congress. The goals of the task force are not only to follow these patients and collect data, but also to assure that these patients receive the appropriate urologic care, and educate providers and laypersons.
Although body armor and tourniquets have allowed patients to survive their combat injuries, IED blasts continue to result in significant GU trauma. The groin flap that is meant to extend down from the body armor vest is often not worn or is ineffective in shielding the groin from IED blasts. The British Army has begun to issue boxer underwear to their deployed troops which contain Kevlar fabric meant to protect the external genitalia and femoral vessels. The advantage of this design is that the external genitalia are totally encased by the Kevlar fabric.
About the Author
Steve Waxman is a Colonel in the U.S. Army Reserves. He deployed to Baghdad, Iraq in 2007 and Bagram, Afghanistan in 2010.
These testis war injuries highlight the importance of "Fertility Preservation in the Male", a topic that will be covered later, in this series of articles. Sperm freezing prior to being deployed for combat should be considered for all military personnel. However, this process may be costly.
We now have better sperm retrieval technology and a better understanding of the ability of sperm to survive in suboptimal environments. Providing the battlefield hospital with the tools to preserve testis tissue (especially in men with bilateral testis injuries), is simple to do, not time consuming, requires few reagents and a small amount of space. As we gain more knowledge of the incidence and frequency of these injuries, "fertility preservation" concepts until now only identified for cancer patients should be utilized in other situations where they may be helpful.
-Stanton Honig, MD