Immediate surgical management of combat-related injury to the external genitalia

Abstract

Patterns of survivable injury after combat injury have changed during recent years as wounding mechanisms have altered, ballistic protection has improved and the military chain of trauma care has evolved. Combat casualties now survive injuries that would have been fatal in previous wars and service personnel can be left with injuries that have significantly detrimental effects on their quality of life. Severe, destructive injuries to the external genitalia are rarely life-threatening, but can be profoundly life altering and the immediate management of these injuries deserves special scrutiny. The general principles of haemorrhage control, wound debridement, urinary diversion, and organ preservation should be observed. An up-to-date review of the management of these relative rare injuries is based on recent, albeit scanty literature and the experiences of managing casualties in the medical evacuation chain of the United Kingdom Defence Medical Services. The rationale behind the current emphasis on post-injury fertility preservation is also discussed.

Infertility and the Military Male

“…In the United Kingdom, early sperm retrieval after injury is the first choice recommendation for casualties with severe testicular injury entering the UK evacuation chain. 47 Certainly, the geographic location of the United Kingdom is much closer to recent contingency operations in the Middle East and Southwest Asia, and logistically such a plan would be much easier for the United Kingdom to accomplish than for the United States. Additionally, American military facilities abroad do not currently have the logistical capabilities or facilities for sperm cryopreservation and transportation.…”

“…When a patient with a complex GU injury enters the British casualty evacuation chain, the higher level facility is alerted, and sperm retrieval is performed by a medical team including a urologist, a trauma surgeon, and a reproductive medical specialist. 47 Sperm retrieval occurs at the first available opportunity employing techniques such as microscopic testicular sperm extraction or epididymal sperm retrieval. Microsurgical techniques are an advantage in testicular injuries sustained from blasts where there may be limited testis tissue available for salvage.…”

“…It is important to remember that these approaches assume that sperm harvest is more valuable to patients than attempts at testicular salvage and conservation and that sperm harvested will be functional for assisted reproductive techniques. 47 These issues remain unanswered questions.…”

Traumatic andropause after combat injury

“…With the absence of viable testicular tissue, sperm retrieval was attempted from the remaining vas deferens, as per protocol 1. The perineal and lower extremity wounds were managed by repeated debridement and topical negative pressure dressings.…”

“…Initially, the main focus of treatment for patients with traumatic testicular loss is haemostasis, resuscitation and management of the likely concurrent life-threatening injuries 1. In addition, early sperm retrieval is advocated to mitigate the possible consequences of later testosterone therapy on spermatogenesis 6.…”