External male genital injuries are rarely life-threatening, but injuries to the male genitalia may induce long-term sexual and psychological damage when injuries are not successfully treated. Male genital trauma has become increasingly common due to high velocity bullets, low velocity bullets, IEDs (Improvised Explosive Device), knifes and other weapons commonly used during wartime. Low velocity bullets travel less than 1,000ft. /sec. and can lacerate and crush tissue; the severity of damage is dependent on energy released due to the mass of the bullet and square of its velocity (Brandes, S. B. MD, Buckman, R. F. MD, Chelsky, M. J. MD and Hanno, P.M. MD, 1995). High velocity bullets therefore, increase the total surface area damaged (Brandes, S. B. MD et al., 1995). IEDs are the most intense weapon used, the explosive device blasts directly upward, IEDs are triggered from movement on the ground (feet of civilians, vehicles or coalition forces) lower extremities and genitalia are often the first to be affected. Casualties that encounter these harmful devices to the male genitals may endure burns, lacerations, blunt trauma, penetrating trauma or partial amputations of specific structures (Morey, A. F., Metro, M. J., Carney, K. J., Miller, K. S., and McAninch J. W., 2004). Removal or trauma to these structures may impair the function of the specific structure. The ultimate goal within medicine is to treat these patients and preserve fertility, erection, testicular hormone secretion/regulation and micturition. Upon admittance to a hospital, first examinations are regularly conducted on each patient, which will dictate the severity of trauma and necessary actions to take in order to preserve and restore injured genitourinary injuries (GU injuries).
The “normal” human penis external structures are the head, corona, body and root of the penis. Internally, the penis has two structures known as the Corpora Cavernosum; these are highly vascular and fill with blood during an erection. Corpus Spongiosum is a membrane that surrounds the Urethra—this structure does not change in size, but increases in length during an erection. Nerves innervate the penis through left and right dorsal nerves apart of the sensory nerve system. The penis is highly vascular; the Internal Pudendal artery supplies the penis and branches off into the Bulbar and Urethral artery. The deep artery of the penis branches into Cavernosal arteries, which supply the Corpus Cavernosum; Urethral arteries supply the head of the penis and Corpus Spongiosum. The Bulbar artery supplies the Bulbar Urethra and the Bulbospongiosus muscle, the penis being highly vascular can result in serious problems once injured. Inhabiting a serious injury, the penile length required for stand void is about 2-3cm; however length may need to be increased to achieve sexual intercourse depending on partner(Santucci, R. A. MD, and Schwartz, B.F., 2011).
Penile trauma varies from mild to severe; during wartime most the injuries are severe and may result in pain, curvature, amputation, urethral stricture and erectile dysfunction. About 50% of GU injuries are due to IEDs; 80% of the individuals endure penetrating trauma and the other 20% blunt trauma (Waxman, 2008). Penile injury is higher if the individual has an erection during the time of trauma—severe hemorrhage occurs and immediate surgery is required (Santucci, R. A. MD, and Schwartz, B.F., 2011). Hemorrhage occurs in high volumes due to dilation of blood vessels within the Corpora Cavernosum controlled by the Autonomic Nervous System (ANS). Damage to the Corpora Cavernosum either unilateral or bilateral poses severe problems within vasculature and must be surgically repaired. This injury typically results in full sexual function; medical devices may also be used to ensure erection (Santucci, 2011). Erectile capacity is usually salvaged after closure even if severe damage occurs to the Corpora Cavernosum. Large wounds to the penis must be covered with dermis, venous and tunical patches, there is a high risk for erectile dysfunction, impaired connection of epithelium and penile curvature (Santucci, 2011).
Injury to the penis is also a consequence of gunshot wounds and stabbings aside from IEDs. These penetrative injuries must be examined immediately to determine severity. Stabbing or gunshot wounds to the penis involve multiple structures such as the Vas Deferens (prone to becoming transected bilaterally). The Vas Deferens is a tubular structure necessary to contain traveling sperm during maturation of the sperm and ejaculation; this structure must be repaired or infertility results. Severity of trauma increases with the number of bullet or stab wounds (Waxman, 2008).
Inside the Scrotal Sac lie several important structures that contribute to fertility and hormone regulation. Testes obtain a biological mechanism known as the Cremaster muscle, which helps to inhibit the testes from being damaged; the testes are able to move superior or inferiorly, however, this does little to protect the Testes due to blasts and penetrating trauma. Testes are lined with two coverings peripheral to deep: Tunica Vaginalis (connective tissue covering to anchor and protect) and Tunica Albuginia (divide testes into lobules). Testes consist of seminiferous tubules, which increase the surface area of the testes and are responsible for the development of sperm from spermatogonium to spermatozoa. Seminiferous tubules proceed to the Rete Testis, Tubuli Recti and Efferent Ductule to the Epididymis where sperm and then transported through a long loop up the Vas Deferens and endure maturation throughout the migratory process. Scrotal injury may lead to impaired fertility, chronic pain and low hormone levels (Santucci, 2011).
Scrotal injury involves mostly penetrating trauma, lacerations and hematomas (blood collection outside vasculature) with a 74.4% salvage rate; over half testicular injuries are due to an open scrotal wound and ruptured Tunica Albuginea (Waxman, 2008). Low velocity bullets reveal fertility conservation in 62% of patients, high velocity bullets reveal failure to preserve the testes 90% of the time due to the inelasticity of connective tissue within the tunica albuginea (Van Der Horst, C., Portillo, F. J., Seif, C., Groth, W., and Junemann, K. P., 2004). Testes often “explode” upon impact of a high velocity missle; semen analyses are conducted on patients after surgery to examine sperm count, motility and morphology. Typical sperm count in post-surgical patients was between 60-120 million, motility was at 70%-80% (normal above 60%), morphology was at 60%-70% (normal above 60%) and one patient was sufficient at fathering a child (Hudak S. J., and Hakim S., 2009). Therefore, ferility may be salvaged if one or both of the testes are repaired or reconstructed immediately. However, if the testes are completely removed there is very little if no fertility or hormone regulation within the male.
According to Hudak S. J., and Hakim S. (2009), the rates of overall surgical procedures within the male at Balad Air Force Theature Hospital relay the following results:
|Surgical management for GU injury at Balad AFTH, 2005 to 2008||Operation No. Procedures|
External ureteral drainage
Total No. upper GU operations
Primary urethral realignment
Exploration /or scrotal injury repair no testicular injury
Exploration /or penile injury repair, no glanular/urethral/corporeal injury
Glanular /or corporaeal repair
Testicular adnexa repair
|Total No. lower GU operations||314|
High counts of genital trauma resulting during wartime are seen in various locations within the human body. Several systems are generally affected; along with the reproductive system, the urinary system tends to have high association during trauma. Repair to the testes requires immediate attention and therefore, results in the most traumatic affects in the male reproductive system. Several aspects within the system become compromised and depending on damage can lead to sterility and failure to reproduce. Wartime is a sacrifice that involves loss of structures and functions of systems when extensive injury occurs; male genitals becoming an increasing target due to high velocity missles.