Management of External Genitalia Gunshot Injuries and Traumatic Avulsions in Civil and Military Conflicts
This chapter summarizes evaluation and management of penetrating projectile (gun-shot wound – GSW) trauma to the external genitalia, reviewing current literature and guidelines where available, as well as the authors’ personal experience and expertise.
The chapter starts by reviewing the epidemiology of trauma to the external genitalia and goes on to describe wound ballistics and mechanisms of low and high energy injuries, as well as avulsion injuries.
The care of patients presenting with these injuries is then explained, including evaluation with physical exam, use and utility of different imaging modalities, and when necessary, surgical management.
Introduction: This chapter seeks to provide step-by-step management of penetrating penile and scrotal trauma in civilian and military conflicts. Where possible, validated evidence and guideline based recommendations are made. In areas that lack large validated studies or clear guidelines, we offer clinical expertise in the management of complex genital gun-related trauma. The reader should be able to use this as a general resource for better understanding of penetrating genitourinary (GU) trauma as well as a specific guide to those presented with patients with GU trauma.
Epidemiology: Penetrating GU trauma most commonly involves the kidney. In trauma of the lower genitourinary tract, >75% of injuries involve the penis and/or scrotum. There should always be a high index of suspicion for concomitant injury to other structures (bladder, rectum, etc.) when there is penetrating injury to the penis/scrotum.
Injury Mechanics: The chapter discusses detailed evidence regarding wound ballistics and the effect on surgical management. Generally, penetrating injury can be divided into high and low energy injury. High energy injury should be suspected in rifle or other high velocity ballistic injury and has the most significance in military conflict.
Patient Assessment: This section provides an evidence based algorithm to the patient with GU trauma. History and physical exam augmented with appropriate and timely imaging is the mainstay of the trauma assessment.
Penile, Scrotal and Avulsion Injuries: These sections cover the surgical approaches and management of lower GU trauma (excluding injuries to the bladder). In patients with penile injuries, the practitioner should have a high index of suspicion for injuries to the urethra, bladder, and other pelvic structures. Scrotal ultrasound is a safe, rapid, and effective imaging modality for assessment of testicular injury. In the setting of clear deep penetrating trauma to the scrotum, even with equivocal scrotal ultrasound, surgical exploration should be undertaken. Avulsion injuries should be attempted to be repaired if the phallus has been properly stored. Additionally, prompt psychiatric evaluation if self-mutilation is considered. In all injuries to the lower GU tract, management priorities should be stabilitization of other injuries, urinary drainage, and repair that minimizes long term morbidity.
High Energy Injuries: We offer this section separately, as individuals with these injuries are often in areas of armed conflict with significantly different risks and different access to care. In general, high energy injuries to the external genitalia should carry an even higher index of suspicion for concomitant severe injury. Additionally, high energy injuries/wounds can be difficult to assess in the acute setting. If there is question of wound viability, urinary diversion and observation with staged reconstruction is often employed. This is particularly true in settings where prompt stabilization is required.
KeywordsPenis injury Scrotum injury External genitalia trauma Genital gunshot wound Genital reconstruction Penetrating genital trauma Avulsion
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