By Annette M. Boyle
SAN ANTONIO — Recent improvements in battlefield medical care have allowed more servicemembers to survive devastating injuries. At the same time, the number of wounded warriors with genitourinary injuries has shot up sharply, with life-altering consequences the DoD and VA are just now coming to fully understand.
An analysis of genitourinary (GU) injuries in nearly 1,400 U.S. servicemembers found that new treatments for and greater attention to the impact of these injuries on all aspects of life is sorely needed, according to a study published recently in The Journal of Urology.1
“Deployment-related GU trauma is a uniquely-devastating injury that has become increasingly common during the recent wars in Iraq and Afghanistan,” said lead investigator Lt. Col. Steven J. Hudak, MD, Urology Clinic, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX.
“We found in both the clinical evidence and the epidemiological evidence that the severity of genitourinary injury parallels the severity of polytrauma injury. These young servicemembers are facing challenges from amputation, head and neck injuries, abdominal injuries and traumatic brain injury,” he told U.S. Medicine. GU injuries can complicate an already-challenging course of recovery by adding urinary, sexual and reproductive dysfunction to the mix.
“The impact of sexual and reproductive problems may be amplified for younger individuals who are still in the process of sexual identity development, who are unmarried and/or who wish to father children,” Hudak emphasized.
That is the primary reason for a recently-adopted interim rule allowing access to in vitro fertilization (IVF) treatment covered by VA for veterans whose combat-related trauma left them infertile. DoD and the TRICARE program already provide advanced fertility treatments, including assisted reproductive technology, to troops with complex injuries.
Hudak and his colleagues analyzed records from the Defense Trauma Registry of more than 29,000 servicemembers wounded during Operation Iraqi Freedom and Operation Enduring Freedom and found that 1,367 survivors sustained GU injuries. These men became the subjects of the Trauma Outcomes and Urogenital Health (TOUGH) project, which studied the epidemiology and long-term outcomes of GU injuries in the recent conflicts.
The researchers found that, during these two conflicts, the external genitalia was the most common area of GU injury (73.2%), largely because of improvised explosive devices (IED). More than one-third (36.7%) of patients with any GU injury had severe testicular or penile injuries, including 146 who sustained loss of one or both testes.
The injuries occurred most often in those younger than 30 years old, 81.4%, junior enlisted servicemembers, 59.6% and members of the Army or Marines, 95.6%. Battle injuries predominated, 88.6%, and the primary mechanism of injury was explosive, 74.1%, resulting in penetrating injuries, 66.6%, according to the report.
“The challenges servicemembers face vary based on what anatomical loss they experience and the degree of functional recovery they achieve,” Hudak noted. “Skin loss can be replaced with a skin graft, but it will look different.” That can be uncomfortable for a young man in a new sexual relationship.
Similarly, “it’s not normal to talk to your buddy about taking Viagra or sexual support therapies in your 20s or 30s. These young veterans need someone who understands the need for that care and can help them discuss it with sexual partners when the need arises.”
For many of the soldiers and marines in the study, the full impact of their injuries did not become apparent until years later. “The scrotum and testes are the most-common areas of injury, making fertility a challenge, but it often not an issue right away,” Hudak pointed out. “We may see patients a decade later, and they are only now thinking about childbearing. That’s making us consider the longitudinal impact on fertility.”
Patients who had severe blast injury to the pelvis may also suffer testicular atrophy and infertility, without any overt testicular injury, study author noted.
Under a new pilot program, current servicemembers can bank their gametes prior to deployment. Post-injury sperm salvage is also an option and is the standard of care for British servicemembers with testicular injuries today. For those rendered infertile as a result of GU injuries in OEF and OIF, however, the only option for paternity is donor sperm, which previously has not been a covered benefit.
Aside from reproduction, GU injuries might also result in loss of sexual function. While only five of the men in the TOUGH study suffered total penile loss, reconstructive surgery left some of the men who had suffered the most-severe penile injuries with a disfigured or nonfunctional phallus. The authors suggest that deceased donor penile transplantation and regenerative medicine approaches could be worth exploring to help servicemembers who suffer these injuries in the future.
Beyond the severity of the GU injuries themselves, recovery can be complicated by the constellation of other injuries with which they often occur, including traumatic brain injury (40.2%), lower extremity amputation (28.7%), pelvic fracture (24%) and colorectal injury (21.7%).
For polytrauma patients, in particular, “we’ve told them, ‘Get better first, worry about sex and intimacy later.’,” Hudak said. “For those who have more severe anatomy-altering injuries, having someone who can talk about the injuries with the servicemember and their partner would significantly improve care.”
Sexuality and reproduction end up further down the rehabilitation priority list because they have not always been considered major activities of daily living.
“Sexuality is an important aspect of daily life. So is urination. But they have not been part of the polytrauma repertoire,” Hudak explained. “Physical therapists need to be talking about specifics—positioning, hand function, other aspects that support this part of daily living, whether a patient has a genitourinary injury or not.”
After the initial recovery period, physicians can support military trauma patients and specifically those with genitourinary injuries by simply recognizing that the injuries may continue to affect their patients’ lives in important ways.
“It’s hard for patients and it’s hard for medical providers who don’t talk about sex and intimacy regularly to bring it up. They need to ask, ‘Are you having difficulty with sex, difficulty having an erection, pain with sex, challenges with urination?’ Hudak said. “There’s no lack of support for individuals who are referred. We can treat all manner of injury. We just have to ask the questions that are difficult to discuss. Almost invariably patients, are relieved to have someone to talk to about these issues.”
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
In community-based, long-term care facilities, collaborative programs have been successful in reducing catheter-associated urinary tract infection (CAUTI) rates.