I would like to thank the Subcommittee on Disability Assistance & Memorial Affairs and the Subcommittee on Health of the House Committee on Veterans’ Affairs for your invitation to testify about urotrauma, a specific battlefield injury affecting a growing number of wounded military service personnel. Urotrauma is the term coined to refer to physical injury to the genitourinary system.

We are receiving reports from our physician members, particularly from our urologists who have recently served in the armed forces in Iraq and Afghanistan, that urotrauma is an increasingly prevalent condition among our active military personnel and veterans. An escalating number of soldiers suffer extensive, debilitating injuries to the genitourinary system. These injuries have far reaching effects for years to come—including impaired sexual function and difficulty conceiving children.  While not as readily apparent as the loss of limb or scarring to an exposed area of the body, urotrauma is a serious and growing problem.

Urologists are disturbed that the knowledge and practice base is inadequate to meet this challenge. The American Urological Association (AUA), on behalf of its concerned surgeons, welcomes the opportunity to provide testimony and raise awareness about this condition.

I am Beth Kosiak, Ph.D., the head of Health Policy for the AUA, a member organization that represents over 92 percent of the more than 10,000 practicing urologists in the United States and over 16,000 world-wide. The long-standing mission of the AUA is to promote the highest standards of clinical urological care through education, research, and formulation of health care policy.   Urologists are the specialists who most often diagnose and treat prostate cancer, the second leading cause of cancer deaths among men in the United States.  In addition, urologists diagnose and manage the care for kidney stones, urinary incontinence, urinary tract infections, and benign prostatic hyperplasia (BPH), among other conditions.

There is insufficient data regarding the management of wartime genitourinary trauma. Neither a recent comprehensive review that examined available data from the 1960s to the present, nor a one- year retrospective review of the United States Army trauma registry revealed substantial information on genitourinary trauma.  While this latter registry provides valuable data on combat injuries, it does not record data specific to each genitourinary organ, nor does it detail what treatment modalities were used by urologists to manage genitourinary trauma.

This dearth of data presents serious challenges to the appropriate diagnosis and management of these injuries.

As battlefield rescues increase, more returning service personnel, particularly those who are victims of Improvised Explosive Devices (IEDs), are living with urotrauma injuries.  Unfortunately, physicians must treat patients without the benefit of knowledge of the most effective treatments.  Injury to urogenital organs accounts for between 1% and 12.5%[1] of all war injuries and most are associated with multiple lesions, especially abdominal.

Most injuries observed during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) were due to IEDs and other explosive ordinance, and gunshot wounds.  The extensive soft tissue loss seen with blast and high velocity bullet injuries necessitated a staged approach to genital reconstruction in many patients.

More information needs to be gathered on the use of modern body armor in the prevention or minimization of genitourinary injury and to encourage improvements in the design of body armor to better protect the genitourinary area.  The Joint Theater Trauma Registry was used to conduct a retrospective study of 2,712 trauma admissions to a United States Army Combat Support Hospital in Iraq. Casualties wearing body armor had a 2.1% rate of genitourinary injury versus 3.4% for those not wearing body armor.

The Department of Defense (DOD) is sponsoring a major effort to focus on traumatic brain injury (TBI), and considers this one of the signature military medical challenges facing the Department for years to come. The DOD will fully implement a comprehensive TBI registry including a single point of responsibility to track incidents and recovery and expand corresponding treatment services.  This effort provides a strong model for genitourinary trauma for which dedicated research on prevention and appropriate treatment could minimize long-term/permanent damage, and encourage the development of more effective body armor.

Given the urgent need for better data, information and clinical practice knowledge to treat and  rehabilitate servicemen and women who experience such injury, the AUA has already taken several steps and  plans to take more.

First, and most significantly, we have authored a bill recently introduced in the House by Representatives Zack Space (D-OH) and Carol Shea-Porter (D-NH), H.R. 5106, which would establish an Interagency Commission on Urotrauma, led by the U.S. Department of Defense, to investigate and advise on the research and action needed to advance treatment of this important condition. The urotrauma legislation includes the following key provisions:

• Creation of “The National Commission on Urotrauma,” which will conduct a comprehensive study of the present state of knowledge and research on urotrauma, evaluate existing education and research resources, and identify knowledge and programmatic gaps.
• A long-range plan, based on the Commission’s comprehensive study, for the use and organization of national resources to effectively deal with urotrauma, including: 1) researching innovations in the care and treatment of persons affected by urotrauma, 2) identifying ways to prevent or minimize these types of injuries, and 3) improving education and training to medical personnel caring for these individuals and raising awareness among the general public.

Second, we have prepared and asked the Representatives to circulate a letter to their colleagues that asks for their support for this bill.

Third, the AUA regularly produces evidence-based clinical practice guidelines which are gaining national attention for their scientific rigor, transparent methodology and timeliness.  The AUA’s Board of Directors has approved development of a clinical practice guideline on urotrauma; we anticipate that work will begin early in 2011. Our guidelines are publicly available on our website and are listed on the federal National Guidelines Clearinghouse, sponsored by the Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ). Thus, once completed, the urotrauma clinical practice guideline would be similarly available.

Fourth, we have begun to engage our member urologists, particularly those who have served in military theaters, to provide their expertise to raise awareness and advance treatment knowledge about urotrauma.

Finally, we have reached out to the Deputy Undersecretary for the Office of Wounded Warrior Care and Transition Policy of the Department of Defense, and supplied information in response to their request. We plan to contact other organizations and federal agency offices where appropriate, to help educate relevant parties about urotrauma as well as offer the expertise of our member surgeons.

I thank you for the opportunity to submit written testimony on this important topic, and offer the services of the AUA and its members to the Subcommittees if we can be of any further assistance.

[1] The figure of 12.5% was most recently supplied to us by Michael O’Rourke, head of Health Policy for the Veterans of Foreign Wars (VFW) in a personal communication on May 11, 2010.