Urethral and penile war injuries: The experience from civil violence in Iraq

Abstract

Objective: To determine the incidence, mechanism of injury, wounding pattern and surgical management of urethral and penile injuries sustained in civil violence during the Iraq war.

Patients and methods: In all, 2800 casualties with penetrating trauma to the abdomen and pelvis were received at the Al-Yarmouk Hospital, Baghdad, from January 2004 to June 2008. Of these casualties 504 (18%) had genitourinary trauma, including 45 (8.9%) with urethral and/or penile injuries.

Results: Of 45 patients, 29 (64%) were civilians and 16 (36%) were Iraqi military personnel. The injury was caused by an improvised explosive device (IED) in 25 (56%) patients and by individual firearms in 20 (44%). Of the patients, 24 had penile injuries, 15 had an injury to the bulbar urethra and six had an injury to the posterior urethra. Anterior urethral injuries were managed by primary repair, while posterior urethral injuries were managed by primary realignment in five patients and by a suprapubic cystostomy alone in one. An associated injury to major blood vessels was the cause of death in eight of nine patients who died soon after surgery (P < 0.001).

Conclusion: Urethral and penile injuries were caused by IEDs and individual firearms with a similar frequency. Most of the casualties were civilians and a minority were military personnel. Injuries to the anterior urethra can be managed by primary repair, while injuries to the posterior urethra can be managed by primary realignment. An associated trauma to major blood vessels was the leading cause of death in these casualties.

Keywords: Civil violence; GU, genitourinary; IED, improvised explosive device; Penile War injuries; Trauma; Urethral.

Figure 1

An ‘up-and-down’ urethrogram showing a bullet fragment (arrow) retained in the region of posterior urethral disruption. The proximal urethral segment was not filled by contrast medium in this film.

Figure 2

A cystogram after filling the bladder from a suprapubic catheter showing multiple bullet fragments inside the pelvis and perineum. The patient had been shot by a high velocity US M16 automatic rifle from a distance of ≈3 m. The bullet fragments resulted in testicular injury, disruption of the posterior urethra, injury to the rectum and fracture of the coccyx.