Author's Accepted Manuscript

Epidemiology of Genitourinary Injuries Among Male Us Service Members Deployed

to Iraq and Afghanistan: Early Findings from the Trauma Outcomes and Urogenital
Health (TOUGH) Project

Judson C. Janak , Jean A. Orman , Douglas W. Soderdahl , Steven J. Hudak

PII: S0022-5347(16)30970-3
DOI: 10.1016/j.juro.2016.08.005
Reference: JURO 13911

To appear in: The Journal of Urology

Accepted Date: 1 August 2016

Please cite this article as: Janak JC, Orman JA, Soderdahl DW, Hudak SJ, Epidemiology of
Genitourinary Injuries Among Male Us Service Members Deployed to Iraq and Afghanistan: Early
Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project, The Journal of Urology®
(2016), doi: 10.1016/j.juro.2016.08.005.

DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a
service to our subscribers we are providing this early version of the article. The paper will be copy edited
and typeset, and proof will be reviewed before it is published in its final form. Please note that during the
production process errors may be discovered which could affect the content, and all legal disclaimers
that apply to The Journal pertain.

Embargo Policy

All article content is under embargo until uncorrected proof of the article becomes available
online.

We will provide journalists and editors with full-text copies of the articles in question prior to the embargo
date so that stories can be adequately researched and written. The standard embargo time is
12:01 AM ET on that date. Questions regarding embargo should be directed to jumedia@elsevier.com.
 ACCEPTED MANUSCRIPT

EPIDEMIOLOGY OF GENITOURINARY INJURIES AMONG MALE US SERVICE MEMBERS

DEPLOYED TO IRAQ AND AFGHANISTAN: EARLY FINDINGS FROM THE TRAUMA
OUTCOMES AND UROGENITAL HEALTH (TOUGH) PROJECT

Word Count: 2,363

PT
Judson C. Janak, PhD1, Jean A. Orman, ScD1, Douglas W. Soderdahl, MD2, and Steven J.
Hudak, MD2

RI
1
United States Army Institute of Surgical Research

SC
JBSA Fort Sam Houston, TX 78234
2
San Antonio Military Medical Center

U
JBSA Fort Sam Houston, TX 78234 AN
Correspondence:
LTC Steven J. Hudak, MD
Urology Clinic, Department of Surgery
M

San Antonio Military Medical Center

3551 Roger Brooke Dr.
D

JBSA Fort Sam Houston, TX 78234

TE

Telephone: 210-916-1163
Fax: 210-916-5076
Email: Steven.J.Hudak2.mil@mail.mil
EP

Conflict of Interest and Source of Funding: The authors declare no conflicts of interest.
C

Support and funding for this study was provided in part by an appointment to the
AC

Internship/Research Participation Program at the United States Army Institute of Surgical

Research, administered by the Oak Ridge Institute for Science and Education through an
interagency agreement between the US Department of Energy and EPA.

Running head: Genitourinary Injuries Sustained During OIF/OEF

Keywords: genitourinary injury, blast-related injury, penile transplantation, gamete preservation

 ACCEPTED MANUSCRIPT
1

Purpose: The objective of this study was to report the number, nature, and severity of

genitourinary (GU) injuries among male US service members (SMs) deployed to Operations

Iraqi Freedom (OIF) and Enduring Freedom (OEF).

PT
Materials and Methods: This retrospective cross-sectional study of the Department of Defense

Trauma Registry used International Classification of Diseases, Ninth Revisions, Clinical

RI
Modifications codes to identify SMs with GU injuries and Abbreviated Injury Scale codes to

SC
determine injury severity, GU organs injured, and comorbid injuries.

U
Results: From October 2001 to August 2013, 1367 male US SMs sustained one or more GU

injuries. The majority of injuries involved the external genitalia (n=1000; 73.2%): scrotum
AN
(n=760; 55.6%); testes (n=451; 33.0%); penis (n=423; 31%); and/or urethra (n=125, 9.1%).

Overall, more than one-third of SMs with GU injury sustained at least one severe GU injury
M

(n=502, 36.7%). Loss of one or both testes was documented in 147 men including 129 (9.4%)
D

unilateral orchiectomies and 17 (1.2%) bilateral orchiectomies. Common comorbid injuries

TE

included traumatic brain injury (n=549; 40.2%), pelvic fracture (n=341; 25.0%), colorectal injury

(n=297; 21.7%), and lower extremity amputations (n=387; 28.7%).

EP

Conclusion: An unprecedented number of US SMs sustained GU injury while deployed to

C

OIF/OEF. Further study is needed to describe the long-term impact of GU injury and determine
AC

the potential need for novel treatments to improve sexual, urinary, and/or reproductive function

among service men with severe genital injury.

 ACCEPTED MANUSCRIPT
2

INTRODUCTION

Improvements in battlefield medical care during the Iraq (October 16, 2002—December

15, 2011) and Afghanistan (October 7, 2001—December 28, 2014) conflicts have led to

unprecedented rates of survival1,2; however, they have also resulted in more US SMs surviving

PT
with GU injuries than ever before in the history of war.3 Severe injuries to the genital and/or

urinary structures can result in sexual dysfunction, urinary symptoms, infertility, and mental

RI
health problems.4-6 Although other common war-related injuries such as extremity amputation

have been well-described,7-10 published reports on the epidemiology and impact of GU injuries

SC
have been limited.11 Identifying the population of SMs with GU injury who might benefit from

U
innovations in rehabilitative and reconstructive medicine only recently highlighted in the lay

media is also important. This information can help ensure that such advances, including penile
AN
transplantation,12 regenerative medicine,13,14 and advanced sperm salvage,15 are targeted to the

needs and preferences of the individuals with these injuries.

M
D

The TOUGH project is a US Department of Defense-funded study to describe the

TE

epidemiology and long-term outcomes of GU injury among SMs wounded in OIF and OEF. The

primary aim of this report on the TOUGH cohort is to describe the number, severity, and nature
EP

of GU injuries sustained by male US SMs while deployed to OIF/OEF.

C

MATERIALS AND METHODS

AC

We analyzed data from the DoDTR from October 2001 to August 2013. The DoDTR is a

US military trauma registry designed to collect data from the medical records of trauma patients

treated at US military hospitals deployed to support combat operations. The DoDTR includes

patients with battle- or non-battle injuries who were admitted as inpatients to a Role 3 medical

facility (the in-theater equivalent of a civilian trauma center) or a higher level of care within 72
 ACCEPTED MANUSCRIPT
3

hours of the injury. Battle injuries were defined as any injury sustained while engaged in combat

with enemy forces (i.e. bullet wound, improvised explosive device blast, flame burn, etc.).

The TOUGH study cohort consisted of all US SMs in the DoDTR with one or more GU

PT
injuries. GU injury was defined as sustaining one or more injuries to any organ or structure

within the GU and/or reproductive system(s) as represented by any one of fifty ICD-9-CM

RI
codes. Genital injury was defined as sustaining at least one injury to the penis, testis, scrotum,

SC
and/or urethra. ICD-9-CM procedure codes were used to identify patients in whom penile

amputation, unilateral orchiectomy, and/or bilateral orchiectomy was documented. AIS codes,

U
as reported in the DoDTR, were used to define a severe GU injury as sustaining either a (1)

serious GU injury (AIS severity score ≥3) or (2) a major to massive laceration to any GU organ.
AN
We identified more severe TBI (type 1 and 2) from ICD-9-CM codes according to the Barell

matrix16 classification. Based on ICD-9-CM codes, all traumatic lower unilateral and bilateral
M

extremity amputations were identified. Using corresponding AIS codes, all lower extremity
D

amputations were further subcategorized as unilateral or bilateral at/above the knee

TE

amputations (yes vs. no). AIS codes were also used to identify patients who sustained comorbid

colorectal injury and pelvic fracture.

EP

In order to compare SMs with severe GU injury versus less severe GU injuries, Chi-
C

square tests were performed. A type 1 error rate of ≤0.05 was considered statistically
AC

significant. All statistical analyses were performed using SAS v9.2 (Cary, NC). This study was

conducted under a protocol reviewed and approved by the Brooke Army Medical Center

Institutional Review Board and in accordance with the approved protocol (BAMC#

C.2014.079d).

RESULTS
 ACCEPTED MANUSCRIPT
4

During the 12 years reviewed, 29,077 US SMs had injury codes available for review in

the DoDTR. Among them, 1,462 (5.3%) sustained one or more GU injuries (TOUGH study

cohort). After excluding female SMs (n=20) and SMs who died of wounds (n=75), the final

analytic sample was comprised of 1,367 male US SMs (Table 1). More than one-third of these

PT
SMs sustained at least one severe GU injury (n=502, 36.7%). The majority were young (age

<30 years: n=1,113; 81.4%); junior enlisted (n=814; 59.6%); and members of either the US

RI
Army or US Marine Corps (n=1,307; 95.6%). The majority of GU injuries were sustained in

SC
battle (n=1,210; 88.6%). In addition, GU injuries were predominantly caused by an explosive

mechanism (n=1,011; 74.1%) which caused penetrating injuries (n=910; 66.6%). SMs with

U
severe GU injuries had a higher proportion of severe polytrauma (Injury Severity Score ≥16:

79.3% vs. 52.1%; p<0.0001).

AN
The majority of individuals had at least one injury to the external genitalia (n=1000;
M

73.2%). The specific external GU organs injured were: scrotum (n=760; 55.6%); testes (n=451;
D

33.0%); penis (n=423; 31%); and/or urethra (n=125, 9.1%) (Figure 1, total adds to more than
TE

1000 because individuals could have more than one type of external genitalia injury). A minority

of scrotal (n=88; 6.4%) and penile (n=86; 6.3%) injuries were severe; however, the majority of
EP

testicular injuries were severe (n=284; 20.8%). Loss of the entire phallus and/or one or both

testes was documented in 147 men including 129 (9.4%) unilateral orchiectomies, 17 (1.2%)
C

bilateral orchiectomies, and less than five penile amputations (data not shown).
AC

Frequently identified comorbid injuries included TBI (n=549; 40.2%); pelvic fracture

(n=341; 25.0%); and colorectal injury (n=297; 21.7%) (Table 2). Compared to those with less

severe GU injuries, the proportion of SMs with severe GU injuries having comorbid colorectal

injuries was nearly double (31.1% vs. 16.3%; p<0.0001). Lower extremity amputation was

identified in more than one-quarter of SMs with GU injury (n=387; 28.7%); furthermore, the
 ACCEPTED MANUSCRIPT
5

majority of amputations were at or above the knee (n=300; 22.0%). Compared to those with less

severe GU injuries, the proportion of bilateral at or above the knee amputations was more than

three times higher for SMs who sustained a severe GU injury (10.8% vs. 3.0%; p<0.0001).

PT
DISCUSSION

RI
This study represents the largest and most comprehensive review of military GU injuries

SC
ever reported. The results demonstrate three key findings: (1) the external genitalia was the

predominant GU region in which US SMs sustained GU injury during OIF/OEF; (2) severe

U
testicular and/or penile injury occurred in a substantial proportion of our study population; and

(3) GU injuries were often part of a larger constellation of polytraumatic injuries which frequently
AN
included lower extremity amputation(s), colorectal injury, and/or TBI.
M

Our finding that more than three-fourths of our study population had injury(ies) to the
D

external genitalia supports earlier studies from Iraq and Afghanistan which identified a shifting
TE

pattern of GU injury from internal GU structures (i.e. kidney, ureter, bladder) to external GU

structures (scrotum, testes, penis, urethra).11,17,18 The shift in GU injury patterns has been
EP

attributed to three main factors: (1) the widespread use of personal protection equipment (i.e.

body armor) which protects the chest and abdominal organs but not the external genitalia; (2)
C

the rugged terrain in Afghanistan which necessitated SMs patrolling on foot (“dismounted”) and
AC

thus exposed the genitals to injury from ground based explosive weapons; and (3) the increased

survival following complex polytrauma1 including catastrophic genital injuries which in prior

conflicts would have likely been unsurvivable.3,17,19 The increased frequency of external genital

injuries has led to the development, production, and distribution of novel pelvic protection

systems designed to decrease the frequency and severity of genital trauma caused by ground

based explosive attacks.19,20 Currently utilized 2-tier pelvic protection systems include a
 ACCEPTED MANUSCRIPT
6

lightweight, form fitting, boxer-brief-type undergarment (Tier 1) designed to mitigate injury from

low energy projectiles and reduce the penetration of dirt and fine debris into a pelvic wound; and

a thicker, brief-type outer garment (Tier 2) worn over the combat trousers, designed to provide

protection from high energy projectiles. The efficacy of such systems and the frequency of their

PT
use among SMs is an area in need of further study.

RI
Likely due to the demographic norms of military service, we found that 93.6% of US SMs

SC
who sustained GU injury were 35 years old or younger. Thus, many men sustained disfiguring

genital injuries during their peak years of sexual development and reproductive potential.

U
GU injuries have the unique potential to adversely alter both the sexual and reproductive health

of the injured SM.6,21 The impact of sexual and reproductive problems may be amplified for
AN
younger individuals who are still in the process of sexual identity development, who are

unmarried, and/or who wish to father children after redeployment. Further, sexual and
M

reproductive challenges may be exacerbated by co-morbid injuries and outcomes that

D

frequently co-occur with GU injuries.22-26

TE

From this large cohort of male SMs with military GU injuries, we describe the a subgroup
EP

of men males (those with severe GU genital injury) in whom conventional management

techniques to restore the unique and highly specialized functions of the GU system may be
C

inadequate. Permanent infertility is a potential adverse consequence of severe injury to the

AC

male external genitalia. Our findings revealed over 20% of SMs with GU injury had severe

injury to one or both testicles, including 129 men with unilateral and 17 with bilateral testicular

loss. Furthermore, in our clinical practice we have anecdotally identified previously fertile men

who sustained severe blast injury to the pelvis and were (months or years later) subsequently

found to have testicular atrophy and biopsy confirmed non-obstructive azoospermia despite no

evidence of overt testicular injury at the time of initial presentation, presumably due to delayed
 ACCEPTED MANUSCRIPT
7

effects from the initial blast injury. For many of these men, paternity is no longer possible

without the use of donor sperm, which is not a covered benefit for current or former US SMs. In

future conflicts, complete loss of fertility after injury can be avoided with either pre-deployment

sperm cryopreservation (now a covered benefit under a new pilot program)27,28 and/or post-

PT
injury sperm salvage. In the United Kingdom, sperm salvage is the standard of care29,30 for

British SMs who sustain testicular injuries.20 In fact, the sperm salvage program implemented at

RI
the Royal Center for Defence Medicine (Birmingham, UK) has resulted in the birth of biological

children for SMs who otherwise would have been rendered permanently infertile.15

U SC
Loss of sexual function is another critically important potential outcome of severe penile

injury. Many of the 423 men with penile injury in this cohort have been managed with
AN
conventional surgical techniques (at our institution and other military treatment facilities across

the US) including corporal repair, skin grafting, and urethral reconstruction. Such techniques
M

were also sufficient to restore urinary and sexual function for some of the 86 men who sustained
D

severe penile injury. However, for the most severe cases, salvage of penile tissue was not
TE

possible, ultimately resulting in complete loss of the penis at the time of injury (<5 men in this

cohort) or a foreshortened, disfigured, nonfunctional phallus despite conventional reconstructive

EP

surgery. For these men, phallic replacement with autologous tissue is challenged by the high

rate of concomitant pelvic and upper extremity injury, potentially compromising the donor and
C

recipient sites. Due to the profoundly devastating consequences of complete penile loss, there
AC

is growing interest in deceased donor penile transplantation12 and regenerative medicine13

approaches to penile replacement. However, to our knowledge, none of these techniques have

ever been attempted in a US SM following battlefield injury.12 Additionally, we identified

significantly higher levels of overall injury severity, colorectal injury, high bilateral lower extremity

amputation, and TBI among men with severe GU injury compared to those with less severe

injury. The cumulative impact of this pattern of complex pelvic and lower extremity trauma on
 ACCEPTED MANUSCRIPT
8

subsequent candidacy for existing penile transplantation and regenerative medicine protocols is

unknown.

There are limitations to this report. First, because the DoDTR only includes data for SMs

PT
who survive to receive treatment at a Role 3 MTF or higher within 72 hours of the injury, we

were able to report the total number of GU injuries treated in these settings over the reported

RI
time period; however, injuries to individuals not admitted are not included. Thus it is likely that

SC
our population may be biased toward those with more severe GU injury. Second, because we

did not have accurate data on the total number of SMs at risk over the same time period, it was

U
not possible to calculate a true incidence rate. Third, our definition of severe injury was based

on either the descriptive nature of the code as “major or massive” or an AIS score of ≥3. The
AN
AIS system was designed to predict the likelihood of death from injury and has not been

validated as a predictor of disability related to the injured system. Thus, it is unclear whether
M

our definition of “severe” correlates with increased treatment needs during recovery and/or
D

greater disability once all wounds are healed. Finally, individuals with GU injury were identified
TE

and injury patterns described based on data abstracted from medical records and coded

according to ICD-9-CM codes. Because prospective data collection in a war theater is very
EP

challenging, the registry data used in our study remains one of the best sources of data on the

epidemiology of combat-related injuries.

C
AC

Ongoing prospective evaluation of the TOUGH cohort will help to address these

limitations and provide needed information about the long term outcomes following GU injury.

Future work will include the following: comprehensive abstraction of medical records obtained

from US medical facilities to confirm the presence of GU injuries among the members of the

TOUGH cohort and provide more detailed information about care received during their recovery

and rehabilitation; administration of a comprehensive health survey to assess patient-reported

 ACCEPTED MANUSCRIPT
9

outcomes including urinary, sexual, and reproductive function, mental health, and overall quality

of life; and detailed physical assessments to be performed for a select group of the TOUGH

cohort with severe genital injuries. Greater understanding of patient preferences for surgical

reconstruction, transplantation, and fertility procedures will also be pursued. Thus the TOUGH

PT
project will provide much needed data on this unique and challenging injury and will ultimately

assist the medical community in improving the care of future US SMs who sustain GU injuries.

RI
SC
CONCLUSIONS

U
Deployment-related GU trauma is a uniquely devastating injury which has become

increasingly common during the recent wars in Iraq and Afghanistan. GU injury-related urinary,
AN
sexual, and reproductive dysfunction is likely to be highly disruptive during the challenging

course of recovery following complex polytrauma, especially for young SMs. Continued
M

investment and research in GU injury prevention, organ reconstruction/replacement, gamete

D

preservation, and rehabilitation (both physical and psychological) are greatly needed.
TE

ACKNOWLEDGEMENTS
EP

We acknowledge the Joint Trauma System for providing the DoDTR data for this study and Ms.

Susan West and the JTS staff for their assistance in preparing the data set.
C
AC

DISCLAIMER: The views expressed herein are those of the authors and do not reflect the

official policy or position of Brooke Army Medical Center, the US Army Medical Department, the

US Army Office of the Surgeon General, the Department of the Army and Department of

Defense or the US Government.

 ACCEPTED MANUSCRIPT
10

REFERENCES

1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011):

implications for the future of combat casualty care. The journal of trauma and acute care

PT
surgery. 2012;73(6 Suppl 5):S431-437.

2. Holcomb JB, Stansbury LG, Champion HR, et al. Understanding combat casualty care

RI
statistics. The Journal of trauma. 2006;60(2):397-401.

3. Ficke JR, Eastridge BJ, Butler FK, et al. Dismounted complex blast injury report of the

SC
army dismounted complex blast injury task force. Journal of Trauma and Acute Care

Surgery. 2012;73(6):S520-S534.

U
4. Han JS, Edney MT, Gonzalez CM. Genitourinary trauma in the modern era of warfare.
AN
Journal of Men's Health. 2013;10(4):124-128.

5. Frappell-Cooke W, Wink P, Wood A. The psychological challenge of genital injury.

M

Journal of the Royal Army Medical Corps. 2013;159 Suppl 1:i52-56.

6. Wilcox SL, Schuyler A, Hassan AM. Genitourniary Trauma in the Military: Impact,
D

Prevention, and Recommendations. USC Social Work: Center for Innovation and
TE

Research on Veterans & Military Families Policy Briefs and Field Notes. 2015.

http://cir.usc.edu/wp-content/uploads/2015/03/CIR_Policy-Brief_GU-
EP

Trauma_March2015.pdf. Accessed November 4, 2015.

7. Doukas WC, Hayda RA, Frisch HM, et al. The Military Extremity Trauma
C

Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb

AC

salvage following major lower-extremity trauma. The Journal of bone and joint surgery.

American volume. 2013;95(2):138-145.

8. Fleming M, Waterman S, Dunne J, et al. Dismounted complex blast injuries: patterns of

injuries and resource utilization associated with the multiple extremity amputee. Journal

of surgical orthopaedic advances. 2012;21(1):32-37.

 ACCEPTED MANUSCRIPT
11

9. Melcer T, Walker GJ, Galarneau M, et al. Midterm health and personnel outcomes of

recent combat amputees. Military medicine. 2010;175(3):147-154.

10. Penn-Barwell JG, Bennett PM, Kay A, et al. Acute bilateral leg amputation following

combat injury in UK servicemen. Injury. 2014;45(7):1105-1110.

PT
11. Banti M, Walter J, Hudak S, et al. Improvised explosive device-related lower

genitourinary trauma in current overseas combat operations. The journal of trauma and

RI
acute care surgery. 2016;80(1):131-134.

SC
12. Grady D. Penis Transplants Being Planned to Help Wounded Troops. The New York

Times. 2015. http://www.nytimes.com/2015/12/07/health/penis-transplants-being-

U
planned-to-heal-troops-hidden-wounds.html?_r=1. Accessed December 10, 2015.

13. Feltman R. Lab-grown penises are on the horizon, scientists say. The Washington
AN
Times. 2014. https://www.washingtonpost.com/news/speaking-of-

science/wp/2014/10/06/lab-grown-penises-are-on-the-horizon-scientists-say/. Accessed
M

Janaury 28, 2016.

D

14. Kime P. Lab-grown testicles give new hope to wounded vets. 2016.
TE

http://www.militarytimes.com/story/military/benefits/health-care/2016/01/31/lab-grown-

testicles-give-new-hope-to-wounded-combat-veterans/79318196/. Accessed February 5,

EP

2015.

15. Nicol M, North N. Now that's a miracle: The baby born to hero soldier who was too
C

injured to be a dad after being blown up by the Taliban 2016.

AC

http://www.dailymail.co.uk/news/article-3382165/Now-s-miracle-baby-born-hero-soldier-

injured-dad-blown-Taliban.html. Accessed January 28, 2016.

16. Barell V, Aharonson-Daniel L, Fingerhut LA, et al. An introduction to the Barell body

region by nature of injury diagnosis matrix. Injury prevention : journal of the International

Society for Child and Adolescent Injury Prevention. 2002;8(2):91-96.

 ACCEPTED MANUSCRIPT
12

17. Hudak SJ, Morey AF, Rozanski TA, et al. Battlefield urogenital injuries: changing

patterns during the past century. Urology. 2005;65(6):1041-1046.

18. Serkin FB, Soderdahl DW, Hernandez J, et al. Combat urologic trauma in US military

overseas contingency operations. The Journal of trauma. 2010;69 Suppl 1:S175-178.

PT
19. Paquette EL. Genitourinary trauma at a combat support hospital during Operation Iraqi

Freedom: the impact of body armor. The Journal of urology. 2007;177(6):2196-2199;

RI
discussion 2199.

SC
20. Davendra MS, Webster CE, Kirkman-Brown J, et al. Blast injury to the perineum. Journal

of the Royal Army Medical Corps. 2013;159 Suppl 1:i1-3.

U
21. Intimacy After Injury: Therapeutic Advances to Alleviate the Devastating Impact of War

Injury on Fertility and on Physical and Emotional Intimacy. 2014; 1-25. Available at:
AN
bobwoodrufffoundation.org/wp-

content/uploads/2014/10/IntimacyAfterInjuryReport2015.pdf.
M

22. Sorensen MD, Wessells H, Rivara FP, et al. Prevalence and predictors of sexual
D

dysfunction 12 months after major trauma: a national study. The Journal of trauma.
TE

2008;65(5):1045-1052; discussion 1052-1043.

23. Harvey-Kelly KF, Kanakaris NK, Eardley I, et al. Sexual function impairment after high
EP

energy pelvic fractures: evidence today. The Journal of urology. 2011;185(6):2027-2034.

24. Rees PM, Fowler CJ, Maas CP. Sexual function in men and women with neurological
C

disorders. Lancet (London, England). 2007;369(9560):512-525.

AC

25. Cosgrove DJ, Gordon Z, Bernie JE, et al. Sexual dysfunction in combat veterans with

post-traumatic stress disorder. Urology. 2002;60(5):881-884.

26. Williamson GM, Walters AS. Perceived impact of limb amputation on sexual activity: a

study of adult amputees. Journal of sex research. 1996;33(3):221-230.

27. Schmidt M. Pentagon to Offer Plan to Store Eggs and Sperm to Retain Young Troops.

The New York Times. February 3, 2016.

 ACCEPTED MANUSCRIPT
13

http://www.nytimes.com/2016/02/04/us/politics/pentagon-to-offer-plan-to-store-eggs-and-

sperm-to-retain-young-troops.html?_r=1. Accessed February 5, 2016.

28. Kime P. Military's new fertility benefit will let troops freeze their sperm and eggs. Army

Times. January 29, 2016. http://www.armytimes.com/story/military/benefits/health-

PT
care/2016/01/29/militarys-new-fertility-benefit-let-troops-freeze-their-sperm-and-

eggs/79511918/. Accessed February 1, 2015.

RI
29. Sharma DM. The management of genitourinary war injuries: a multidisciplinary

SC
consensus. Journal of the Royal Army Medical Corps. 2013;159 Suppl 1:i57-59.

30. Sharma DM, Bowley DM. Immediate surgical management of combat-related injury to

U
the external genitalia. Journal of the Royal Army Medical Corps. 2013;159 Suppl 1:i18-

20.
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
14

FIGURE LEGEND

Figure 1. Proportion of US Service Members with Severe and Less Severe Genitourinary Injury
Stratified by Genitourinary Structure (n=1,367)

PT
RI
U SC
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

Table 1. Demographic Characteristics of Male US Service Members Sustaining Genitourinary Injury

during Operations Enduring Freedom and Iraqi Freedom Stratified by Severity, 2001-2013

Severe Less Severe Chi-Square

Genitourinary Genitourinary Test
Total (n=1,367) a.
Injury Injury (p-value)
(n=502) (n=865)
Injury Year-No. (%) 26.4 (<0.001)

PT
2001-2008 683 (50.0) 205 (40.8) 478 (55.3)
2009-2013 684 (50.0) 297 (59.2) 387 (44.7)
Age-No. (%) 4.0 (0.26)
18-21 years 371 (27.1) 147 (29.3) 224 (25.9)

RI
22-29 years 742 (54.3) 274 (54.6) 468 (54.1)
30-35 years 167 (12.2) 52 (10.4) 115 (13.3)
>35 years 87 (6.4) 29 (5.8) 58 (6.7)
Branch-No. (%) 0.0001 (0.99)

SC
Army/Marines 1,307 (95.6) 480 (95.6) 827 (95.6)
Navy/Air Force 60 (4.4) 22 (4.4) 38 (4.4)
Rank-No. (%)* 4.9 (0.08)
Junior Enlisted (E1-E4) 814 (59.6) 314 (62.7) 500 (57.8)

U
NCOb. (E5-E9) 476 (34.8) 156 (31.1) 320 (37.0)
Officer (Warrant/Commissioned) 76 (5.6) 31 (6.2) 45 (5.2)
AN
Theater-No. (%) 17.8 (<0.001)
OIF/OND 644 (47.1) 199 (39.6) 445 (51.5)
OEF 723 (52.9) 303 (60.4) 420 (48.6)
Battle Injury-No. (%)* 4.7 (0.03)
Yes 1210 (88.6) 457 (91.0) 753 (87.2)
M

No 156 (11.4) 45 (9.0) 111 (12.8)

Injury Mechanism-No. (%)* 1.9 (0.17)
Explosive 1011 (74.1) 382 (76.2) 629 (72.9)
Non-Explosive 353 (25.9) 119 (23.8) 234 (27.1)
D

Type of Injury-No. (%) 28.4 (<0.001)

Penetrating 910 (66.6) 379 (75.5) 531 (61.4)
TE

Blunt or Burn 457 (33.4) 123 (24.5) 334 (38.6)

Injury Severity Score-No. (%) 112.0 (<0.001)
0-15 518 (37.9) 104 (20.7) 414 (47.9)
16-25 368 (26.9) 148 (29.5) 220 (25.4)
26-55 456 (33.4) 236 (47.0) 220 (25.4)
EP

>55 25 (1.8) 14 (2.8) 11 (1.3)

a.
A severe genitourinary injury was defined as sustaining either a (1) serious genitourinary injury (AIS
b.
severity score ≥3) or (2) a major to massive laceration to any genitourinary organ; NCO: Non-
C

Commissioned Officer; Proportions may not add to 100 due to rounding; *Missing n<5
AC
 ACCEPTED MANUSCRIPT

Table 2. Incidence of Comorbid Injuries among Male US Service Members with Genitourinary Injuries
Sustained during Operations Enduring Freedom and Iraqi Freedom, 2001-2013

Severe Chi-Square
Non-Severe
Total Genitourinary Test
a, Genitourinary
(n=1,367) Injury (p-value)
Injury (n=865)
(n=502)
Comorbid Injuries-No (%)

PT
Colorectal 297 (21.7) 156 (31.1) 141 (16.3) 40.8 (<0.001)
Pelvic 341 (25.0) 160 (31.9) 181 (20.9) 20.3 (<0.001)
Traumatic Brain Injury 549 (40.2) 210 (41.8) 339 (39.2) 0.9 (0.34)
Lower Extremity Amputation-No (%)

RI
Any 387 (28.3) 208 (41.4) 179 (20.7) 67.3 (<0.001)
Unilateral 243 (17.8) 113 (22.5) 130 (15.0) 12.2 (0.001)
Bilateral 144 (10.5) 95 (18.9) 49 (5.7) 59.3 (<0.001)
At or Above the knee 300 (22.0) 171 (34.1) 129 (14.9) 68.0 (<0.001)

SC
Unilateral 220 (16.1) 117 (23.3) 103 (11.9) 30.6 (<0.001)
Bilateral 80 (5.9) 54 (10.8) 26 (3.0) 34.6 (<0.001)
a.
A severe genitourinary injury was defined as sustaining either a (1) serious genitourinary injury (AIS
severity score ≥3) or (2) a major to massive laceration to any genitourinary organ; Proportions may not

U
add to 100 due to rounding
AN
M
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

100%

90%

80%

PT
70%

60%

RI
50%

SC
40%

30%

U
20%
AN
10%

0%
Scrotum Testicle Penis Kidney Perineal Bladder Urethra Ureter
M

Injury Injury Injury Injury Injury Injury Injury Injury

Less Severe 49.2% 12.2% 24.7% 15.3% 4.0% 5.0% 5.8% 2.1%
Severe 6.4% 20.8% 6.3% 5.8% 5.9% 4.5% 3.4% 1.7%
D
TE
C EP
AC
 ACCEPTED MANUSCRIPT

ABBREVIATIONS

AIS: Abbreviated Injury Scale

DoDTR: Department of Defense Trauma Registry
GU: Genitourinary
ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification

PT
OEF: Operation Enduring Freedom
OIF: Operation Iraqi Freedom
SMs: Service Members

RI
TBI: Traumatic Brain Injury
TOUGH: Trauma Outcomes and Urogenital Health

U SC
AN
M
D
TE
C EP
AC