Combat Injuries and Male Infertility


By Steven Waxman, M.D., J.D.

The wars in Iraq and Afghanistan over the past decade, have resulted in over 50,000 United States combat related injuries. Injuries to the genitals or urinary organs accounted for roughly one in twenty of all these injuries in male troops.

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 external genitalia was as follows:

  • Scrotum 29%
  • Testis 9%
  • Penis 14%

The aftermath of these injuries, from both physical and mental standpoints, are as yet unknown.

Blast injuries to 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. A high index of exploration is essential when examining and diagnosing wounds such as these. Small entry wounds to the scrotum may be associated with severe testicular trauma.

There are multiple levels of care in a war zone. Injured patients are systematically evaluated, treated, and typically transported from point-of-injury to larger facilities and eventually, out of the war area entirely. 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, as well as other issues. Also, we must know what additional reconstructive surgeries were performed.

The Army Dismounted Complex Blast Injury (DCBI) Task Force published a report describing the nature, incidence and management of these injuries. 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 a urologist in theater is crucial.

The Army DCBI taskforce is an excellent start towards improving care for these patients. A new task force on uro-trauma has been introduced several times in the United States Congress. The goals of the taskforce are to follow these patients and collect data, as well as to assure that patients receive the appropriate urologic care. The taskforce is also poised to 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 external genitalia and the femoral vessels. The advantage of this design is that external genitalia are totally encased by the Kevlar fabric.

For more information on male factor infertility and combat as well as fertility preservation options for male and female troops, read Path2Parenthood’s handbook, “Combating Infertility During Military Service.”

Additional Sources:

  • Serkin F, Soderdahl D, Hernandez J, Patterson M, Blackbourne L, Wade C.Combat Urologic Trauma in US Military Overseas Contingency Operations. J Trauma 69: S175-178, 2010.
  • Waxman S, Beekley A, Morey A and Soderdahl D. Penetrating trauma to the external genitalia in Operation Iraqi Freedom, International Journal of Impotence Research (2009) 21, 145-148; doi:10.1038/ijir.2008.59.
  • Dismounted Complex Blast Injury: Report of the Army Dismounted Complex Blast Force Injury Task Force. Fort Sam Houston, Texas. June 18, 2011. www.armymedicine.army.mil

Steve Waxman is a Colonel in the U.S. Army Reserves. He deployed to Baghdad, Iraq in 2007 and Bagram, Afghanistan in 2010. The opinions or assertions contained herein are his private views and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Sections of this article were originally published on this website in 2012. Copyright of both articles belongs to Path2Parenthood.


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