By Annette M. Boyle

Since a report last year of the Army Dismounted Complex Blast Injury Task Force documented a sharp increase in the number of genitourinary (GU) injuries among U.S. warriors in Afghanistan, the DoD has taken several steps to better meet the healthcare needs of these fighters — but much remains to be done.

Reducing the number and severity of dismounted complex blast injuries (DCBI) is the first priority because of the devastating physical and psychological effects of genitourinary injuries. The task force report offered anecdotal evidence that some servicemembers have “do not resuscitate” pacts with their colleagues in case of this type of damage.

To help prevent the injuries, Project Manager Soldier Protection and Individual Equipment (PM-SPIE) has been charged with coordinating research efforts focused on improving ballistic undergarments. The task force report noted that as much as 40% of pelvic and groin injuries may be mitigated by use of body armor.

“The prevalence of [improvised explosive devices] during dismounted operations in Operation Enduring Freedom has caused a greater number of injuries to the lower body," according to an Army request for proposals for enhanced protective boxer-style briefs issued this spring. The new undergarments should improve protection of the pelvis, femoral arteries, genitalia and lower abdominal organs in a blast or fragmentation event, according to the RFP. 

The two-layer Pelvic Protection System issued by the Army since June 2011 has an undergarment (PUG) that resembles bicycle shorts made out of a soft, moisture-wicking material on the outer thighs with a tough Kevlar mesh to protect the inner thighs and femoral artery from explosive — and often highly contaminated — debris. The groin also has additional shielding. An outergarment or POG is made of a more-rigid material that offers protection equivalent to that provided by ballistic vests. According to PEO Soldier Live, a blog produced by the Army acquisition agency responsible for everything soldiers wear or carry, the POGs and PUGs have been fielded to approximately 15,000 soldiers.

The Marines soon will issue a three-piece Pelvic Protection System, based on a model used by the British in Afghanistan. Above the PUG and second layer of pelvic body armor, the Marine model will include ballistic knee-length shorts made of heavy, layered Kevlar fabric specifically designed to give extra protection to foot patrols, such as those operating the lead metal detector in teams searching for IEDs. The shorts would be worn over combat trousers.

The BCB Protective Under Garment, shown here on a mannequin, is one of the pelvic protection systems developed by Program Executive Office Soldier. U.S. Army Photo.

Prior to the rollout of PUGs, genitourinary injuries [IEDs] accounted for nearly 5% of combat injuries in OIF/OEF. These injuries affected the scrotum in nearly 30% of cases, the penis in 14% and a testis in 9%, wrote Col. Steve Waxman, MD, JD, in a recent article, “War and Male Genital Trauma” for the  American Fertility Association.

Waxman noted that rates for “saving the testicle(s) in the war zone hospitals have been reported to be as high as 74% in Operation Iraqi Freedom,” adding that a “high index of suspicion is essential when addressing wounds to the external genitalia following an IED blast. Small entry wounds to the scrotum may be associated with severe testicular trauma.”

As GU injuries tend to be extensive in DCBIs, Waxman noted, “the presence of a urologist in theater is crucial.”

Specialty-trained urologists have a “broader knowledge of the future reconstruction strategies anticipated for major penile, scrotal and urethral injuries that should be taken into consideration during acute resuscitation,” agreed DCBI report author Army Brig. Gen. Joseph Caravalho.

Consequently, the Army Surgeon General has directed that the ATO’s Role III facilities have a staff urologist assigned at all times. The Joint Theater Trauma System Clinical Practice Guideline for urologic trauma management updated in April specifically advises that “testicular repair is crucial, even when there is only a small amount of viable tissue present. Conservative debridement and meticulous repair of tissues is crucial in these injuries to preserve hormonal and sexual function.” In addition, Caravalho and the task force noted that the limited number of civilian and military physicians who perform phallic reconstruction surgery indicates a “need to train more military urologists and plastic surgeons in these techniques.”