Outcomes of Genitourinary Injury in U.S. Iraq and Afghanistan War Veterans Receiving Care from the Veterans Health Administration.

INTRODUCTION: In the recent conflicts, unprecedented numbers of US service personnel have survived with genitourinary (GU) injury, but few reports have focused on outcomes of these injuries. Outcomes of combat-related GU injury were investigated in wounded US male veterans of Operations Enduring/Iraqi Freedom and New Dawn receiving Veterans Health Administration (VHA) care. MATERIALS AND METHODS: Department of Defense Trauma Registry (DoDTR) data for male service members injured in theater were linked with VHA electronic health records (EHRs) for veterans who received VHA care at least once from October 2001 through September 2011. Abbreviated Injury Scale scores and International Classification of Diseases-9th Revision-Clinical Modification codes were used to identify GU injuries, severity, and outcomes. Wounded veterans with vs. without GU injury were compared. RESULTS: A total of 12,923 injured veterans were found in both databases; 591 (4.6%) had a GU injury diagnosis in the DoDTR; 18 (3.0% of 591) had a GU injury diagnosis in VHA EHRs. Of the 591 with GU injury, 179 (30.3%) had at least one severe GU injury. The prevalence of both urinary symptoms (6.3% vs. 3.1%; p < 0.0001) and sexual dysfunction (13.5% vs. 7.1%; p < 0.0001) was higher among those with vs. without GU injury, respectively. Traumatic brain injury prevalence was also higher (48.0 % vs. 40.0%; p < 0.0001); post-traumatic stress disorder prevalence was similar between the two groups (51.6% vs. 50.6%). CONCLUSION: We identified an opportunity to improve the diagnosis and coordination of care for veterans with GU injury. Routine screening and better documentation upon transfer from DoD to VHA care should be implemented to alert multi-specialty care teams to provide care for the urinary, sexual, fertility, and psychological health problems of these patients.

A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan.

Importance: Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described. Objectives: To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category. Design, Setting, and Participants: In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014. Main Outcomes and Measures: Primary outcomes were proportion of NBIs and the changes in NBI over time. Results: Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% [604 of 955] vs 33.1% [9599 of 29 003]; P < .001) and in Operation New Dawn (71.0% [298 of 420]) and Operation Iraqi Freedom (36.3% [6655 of 18 334]) compared with Operation Enduring Freedom (29.0% [3250 of 11 204]) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% [539 of 810]) and Navy (48.3% [394 of 815]) than in members of the Army (34.7% [7680 of 22 154]) and Marine Corps (25.7% [1584 of 6169]) (P < .001). Leading mechanisms of NBI included falls (2178 [21.3%]), motor vehicle crashes (1921 [18.8%]), machinery or equipment accidents (1283 [12.6%]), blunt objects (1107 [10.8%]), gunshot wounds (728 [7.1%]), and sports (697 [6.8%]), causing predominantly blunt trauma (7080 [69.4%]). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%). Conclusions and Relevance: In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.

Genitourinary injuries and extremity amputation in Operations Enduring Freedom and Iraqi Freedom: Early findings from the Trauma Outcomes and Urogenital Health (TOUGH) project.

BACKGROUND: In Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF), genitourinary (GU) wounds have occurred in unprecedented numbers. Severe concomitant injuries, including extremity amputations, are common. The epidemiology of GU injury and extremity amputation in OEF/OIF has not been described. MATERIALS AND METHODS: The Department of Defense Trauma Registry was queried from October 2001 through August 2013 to identify all surviving US male service members with GU injuries sustained in OEF/OIF. Genitourinary injury was defined as sustaining one or more injuries to any organ or structure within the genitourinary and/or reproductive system(s) based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was quantified based on Abbreviated Injury Scale scores and overall Injury Severity Scores. The incidence, nature, and severity of GU injuries and extremity amputations are described. RESULTS: Of the 1,367 service members with GU injury included in this analysis, 433 (31.7%) had one or more extremity amputations. Most GU injuries were to the external genitalia [scrotum (55.6%), testes (33.0%), penis (31.0%), and urethra (9.1%)] vs. the kidneys (21.1%). Those with amputation(s) had greater GU injury severity (Abbreviated Injury Scale score ≥ 3) than those without amputations (50.1% vs. 30.5%, respectively; p < 0.0001). Approximately 3.4% of male service members with GU injury had an upper extremity amputation only, 8.9% had both lower and upper extremity amputation(s), and 19.4% had lower extremity amputation(s) only. Of the 387 patients with GU injury and lower extremity amputations, 87 (22.5%) had amputations below the knee and 300 (77.5%) had amputation(s) at/above the knee. CONCLUSION: In OEF/OIF, concomitant GU injury and extremity amputation are common and have serious implications for health and quality of life. This wounding pattern presents new challenges to the military medical and research and development communities to prevent, mitigate, and treat these battlefield injuries. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.