Nearly 1,300 U.S. troops who served in Iraq or Afghanistan suffered some form of genital injury in combat — complex wounds that threaten the ability of these veterans to reproduce, connect with other humans at a basic level and self-identify as virile members of society.
While the number represents just a small fraction of the nearly 52,000 wounded in combat in the two conflicts, they are among some of the most complex combat trauma cases seen by military and civilian doctors.
Now these physicians are stepping up to develop procedures and care to improve the quality of life for these service members.
In previous wars, troops who sustained blasts to their groins and genitalia often did not make it off the battlefield. But improvements in combat trauma care, evacuation and surgery have made it possible for post-9/11 troops with severe lower limb injuries to survive.
This in turn has forced urologists, plastic surgeons and researchers to push the limits of what's possible in the science of rebuilding and regenerating genital organs.
At a two-day conference in Washington in December, Army Maj. Steven Hudak, reconstructive urologist at San Antonio Military Medical Center in Texas, called them "some of the most complex cases we've seen, presented in the context of severe, destructive [multiple injuries] greatly complicating the situation for using established procedures for treatment or novel options for organ reconstruction."
Improved treatment options
In the early days of the wars, the possibility that a soldier, sailor, airman or Marine would lose his genitalia but survive seemed remote. But as enemy tactics increasingly relied on the use of improvised explosive devices, warriors with these injuries began arriving back in the U.S. presenting these cases to military doctors at Walter Reed National Military Medical Center, Bethesda, Maryland, and in San Antonio to patch the injured up as best they can.
Now, medical advancements have improved treatment options, restoring, to some extent, these troops' sense of self.
"Loss of penis or significant genital deformity will significantly influence men's perceptions of their selves and their masculinity," said Dr. Richard Reddett, an associate professor at Johns Hopkins School of Medicine.
In these complex medical cases, the level of damage determines the extent of treatment, according to doctors at the Intimacy after Injury conference, sponsored by the Bob Woodruff Foundation, Johns Hopkins Military and Veterans Health Institute and the Wake Forest Institute of Regenerative Medicine in Washington on Dec. 11-12.
For example, victims with slight damage to the penis or scrotum may simply require a small skin graft from another part of their body to repair cosmetic damage.
Others, including those with a damaged urethra — the tube that carries urine from the bladder through the tip of the penis — require more extensive repair. In these cases, doctors can use the lining from the inside of the mouth to build a urethra, since the moist tissue lends itself well to creating a new tube and the donor site — the mouth — heals quickly.
More extensive injury to the genital region requires more artistry. Surgeons can utilize the skin and tissue of the groin area to rebuild a destroyed penis, wrapping the surrounding tissue around the urethra and other existing tissue to form a new organ.
Creating a new organ
And for those with the most severe injuries — complete loss of the penis — physicians can perform procedures developed to help children born with genital deformities as well as patients undergoing gender reassignment surgery:
In fact, they can actually create a new penis using the skin and tissue of the patient's forearm.
In the procedure, called a radial forearm free flap phalloplasty, surgeons strip the skin off the forearm and remove at least one artery, two large nerves and additional tissue from the arm that will serve as the structure of a new penis.
They create the inside structure from the nerves, blood vessels and tissue and then wrap the structure with the forearm skin, stitching the exterior so it has the shape of a penis. The new organ is carefully attached to the groin vessels, creating a penile replacement with full function — restoring the ability to urinate, have intercourse and have orgasms.
Reddett says the surgery has been a blessing for those who have had it.
"It gives them a pretty realistic phallus. ... We have them get tattoos at three months to give them a realistic appearance and they get an implant for an erection about 12 months after surgery," Redderr said. "We do pretty well with cosmetics. And if you look at sensation, with my 10 patients, 100 percent got sensation and 100 percent can have an orgasm."
The next step
The next step in groin injury advancement could occur within two years: The same team at Johns Hopkins University that has honed face transplant procedures and successfully conducted hand transplants is developing protocols to transplant penises.
In 2005, physicians in China tried to transplant a penis but that operation was unsuccessful and the organ was removed after a couple of weeks.
Using advancements and procedures perfected with their other complex transplant procedures, doctors at Hopkins are confident they will be able to perform a successful transplant.
The surgery presents a unique set of medical challenges, said Dr. Damon Cooney, assistant professor of plastic and reconstructive surgery, since penises are complicated organs with complex vascular and nerve systems that perform multiple functions.
And because they also are, by their very nature, an extremely personal appendage, their transplantation also includes ethical concerns unlike other organ donations, for both donor families who may be squeamish to share and patients who might be reluctant to accept, said Jeffrey Kahn, a bioethicist with the Johns Hopkins Bloomberg School of Public Health.
"We have driver's license check-offs as to whether you want to be a donor. Whether that permission extends to a face, a hand, and even, now a penis, is questionable. We don't think so. This would have to be a separate request made of the family in the name of science," Kahn said.
He also expressed concerns over the privacy rights of the donor's family and the recipient, and the psychological impact on both a patient and their sexual partners of a surgery that involves another man's penis.
No reproduction
Any penis transplant that Johns Hopkins conducts will not involve organs capable of reproducing, he added — no testes, gametes or sperm — so while the patient would have a donor penis, he would not be able to father children unless his own testes were intact.
Research could end up providing the ultimate solution for those who have lost their genitals in accident or injury. Researchers at Wake Forest Institute of Regenerative Medicine are trying to grow a penis from a patient's own smooth muscles and endothelial cells — a development that permit patients to have their own body part.
Unlike a transplant patient, a person whose own penis is regenerated would not have to take the immunosuppressants that transplant patients need to keep their bodies from rejecting a donated organ.
Institute director Dr. Anthony Atala and his team have succeeded in growing rabbit penises and transplanting them to males in their laboratory — research that resulted in successful copulation and baby bunnies.
The team developed the first lab-grown human organ, a bladder successfully implanted into a boy in 2006, and his group has created partial livers and kidneys as well. But a fully functioning human penis may still be a few years off, if possible at all, Atala said at the conference.
"One of the problems with presenting this information in such a quick period of time is people are going to walk away thinking it's so easy — you just plop cells onto a scaffold and you have an organ," he said. "Nothing could be further from the truth."
DoD involvement
Spouses at the conference said they would like to see the Defense Department develop plans to anticipate the possible loss of gentalia and function before troops deploy and share this information with the service members and their families.
They want pre-deployment briefs to include sessions on what to expect if an injury happens and options for family planning prior to deployment, such as freezing sperm.
They also would like to see changes in policy if a service member is injured, including harvesting and freezing sperm within days after an injury.
"If they had taken sperm from Matt when he was injured, it would have made a significant difference in our quest to have twins," said Tracy Keil, whose husband, Matt, became paralyzed from the upper chest and down after he was shot by a sniper.
Family members also said more counseling and medication should be available to troops and spouses affected by traumatic brain injury, a combat mental health disorder or other injury that affects their ability to have sex.
Keil, who has pressed for changes in policy regarding fertility policy and counseling at the Defense and Veterans Affairs departments, said providing appropriate surgical advancements, fertility treatments and the ability to have sex go a long way in making these service members "feel whole."
"I asked him the other night: 'If you could have use of your arms ... or full function of your penis what you rather have?' And he's like, 'I don't care about my arms!' ... I was shocked because all I wanted was a hug," Tracey Keil said. "But hey, he's a guy."
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.
