War Injuries of External Male Genitalia: A Prospective Single-Center Study from the General Military Hospital, Sana’a, Yemen (2022–2024)

Introduction

Genital injuries are clinically significant due to their frequent association with major pelvic and vascular trauma from both blunt and penetrating mechanisms, as well as the potential for chronic impairment following penile and scrotal injuries [¹]. While injuries to the external genitalia are rarely life-threatening on their own, they are often accompanied by other potentially fatal injuries to the abdomen, pelvis, or groin [²]. Traumatic injuries to the genitourinary (GU) tract occur in 2.2–10.3% of hospitalized trauma patients, with external genital injuries accounting for one-third to two-thirds of these cases [³]. Approximately 70% of GU injuries in combat settings involve the external genitalia, representing up to 5% of all military-related trauma [⁴,⁵,⁶]. GU trauma occurs across all age groups but is most common in males aged 15–40 years, with 5% of cases occurring in children under ten years of age [⁷].

The testes, scrotum, and penis are vulnerable to both blunt and penetrating trauma. Testicular injuries may range from contusions to ruptures, while scrotal trauma often involves deep lacerations, burns, or avulsions. Penile injuries include fractures (rupture of the corpus cavernosum), amputations, strangulation, or bite-related injuries, as well as missile injuries [⁸].

Because trauma predominantly affects young individuals, injuries to the external genitalia can profoundly impact health-related quality of life, compromising urinary function, sexual performance, fertility potential, cosmetic appearance, and psychological well-being [⁹].

In Yemen, the ongoing conflict over the past decade has led to a notable increase in war-related male genital injuries, primarily from gunshots, explosions, and blast injuries. However, there is a scarcity of data on the epidemiology, management, and short-term outcomes of these injuries in low-resource, conflict settings. Aim: This study aimed to evaluate the mechanisms, types, and anatomical distribution of war-related external genital injuries, associated injuries, management strategies, and short-term clinical outcomes, including complications, sexual and reproductive function, and cosmetic results.

Patients and Methods

This prospective, single-center study was conducted at the General Military Hospital, Sana’a, Yemen, from April 2022 to March 2024. The study included all consecutive male patients presenting to the emergency department with war-related external genital injuries.

Inclusion criteria were males of any age with war-related external genital trauma. Exclusion criteria included non-war-related injuries, previous genital surgery, or incomplete clinical data.

Data collected included patient demographics, injury mechanism (penetrating vs blunt), anatomical site, associated injuries, time from trauma to hospital presentation and surgery, management approach, intraoperative findings, hospital stay, and follow-up outcomes. Patients were examined systematically, including the penis, scrotum, and perineum, documenting penetrating injuries, scrotal swelling, or hematomas.

Results

Associated Injuries

Concomitant injuries were present in 32 patients (61.5%). Femoral–pelvic fractures were the most frequent associated injury (24/52, 46.2%), followed by vascular injuries (12/52, 23.1%), abdominal–pelvic organ injuries (4/52, 7.7%), and urethral injuries (2/52, 3.8%) Figure 1.

Discussion

Young men are frequently affected by injuries to the male external genitalia. Several studies have documented similar findings: Lee et al., in a 10-year review, reported a mean age of 27.8 years [¹⁰], while Ahmed et al. observed a mean age of 28±3.2 years [¹¹]. In our study, the mean age was 23.3±4.9 years, which aligns with these reports. Diagnosis was primarily based on clinical assessment, followed by emergency surgery. Scrotal ultrasound was performed in 14 patients (53.8%) and was not systematically applied. This approach aligns with Djè and Coulibaly [¹²,¹³], who suggest emergency surgical exploration except in cases of severe trauma. This therapy would decrease the likelihood of problems and aftereffects. The treatment attitude to scrotal injuries is diverse and depends above all on the existence or absence of a hematocele on clinical evaluation [¹⁴].

Mechanisms of injury were predominantly penetrating (84.6%), with blunt trauma representing 15.4%. RTA and gunshot injuries accounted for 68% and 16% of injuries, respectively, in the Ahmed et al. study [¹¹], but penetrating injuries accounted for 79% of injuries in other reports [¹⁵]. This is comparable to the situation in other nations where penetrating wounds are more common [¹⁶]. Gunshot wounds accounted for 38.4%, while explosive devices caused 46.2% of injuries. Penile injuries were noted in 30.8% of patients, lower than the 60% reported in large cohort studies by Bertini and Corriere [¹⁷], likely due to differences in sample size and study period.

All patients underwent prompt assessment and management, including hemodynamic stabilization and urethral evaluation when indicated. Penetrating penile injuries were treated with debridement and exploration, preserving tissue for potential reconstruction, with corpora repaired using absorbable sutures [¹⁸]. Scrotal and testicular injuries were addressed immediately: hematomas were evacuated, necrotic tissue excised, and tunica albuginea closed, using tunica vaginalis flaps in selected cases (15.4% of testicular repairs; 46.2% of hematocele evacuations). Orchiectomy was required in 26.9% of patients with non-viable testes, mostly due to high-velocity gunshot injuries, consistent with previous reports [¹⁹,²⁰].

Penetrating scrotal wounds were generally managed with exploration; partial scrotal skin loss was repaired primarily. Large hematoceles were drained promptly to prevent infection and ischemia, whereas stable hematomas were managed conservatively with rest, ice, and elevation [²¹,²²].

Associated injuries occurred in 32 patients (61.5%), primarily vascular and musculoskeletal, requiring multidisciplinary management. In Ahmed et al.’s study, related injuries were observed in 41% of cases [¹¹]. Mean hospital stay was 5.2±5.1 days, comparable to Coulibaly [¹²] but shorter than reports from Burkina Faso [²²].

At one-month follow-up, 28 patients (66.7%) achieved satisfactory cosmetic and functional outcomes, including good wound healing, acceptable genital appearance, and preserved sexual function. Exceptions included two patients requiring bilateral orchiectomy with subsequent testosterone therapy. Semen analysis, completed in 42 patients, showed normal results in 71.4%, oligoasthenozoospermia in 19.0%, and azoospermia in 9.5%. Early infection was uncommon and managed with local care. Cosmetic and functional outcomes of therapy of penetrating genital damage are usually favorable if adequate, on-time treatment and repair are undertaken [²³]. In testicular injuries, sperm production and sustained hormonal function have been observed in men with adequately bilateral repaired testes after penetrating injuries [²⁴].

Conclusion

External male genital injuries during war are caused by a variety of mechanisms, ranging from minor penile lacerations to complete avulsion of the testes and scrotum. Timely evaluation, meticulous wound irrigation with saline and mild antiseptics, and prompt surgical intervention remain critical for minimizing infection and preserving function. In our cohort, while a majority of patients achieved satisfactory cosmetic and functional outcomes at one month, a substantial proportion experienced complications, including testicular atrophy, abnormal semen parameters, penile deformity, and erectile dysfunction. These findings highlight the need for standardized management protocols for war-related genital trauma and for future multi-center studies with longer follow-up to better assess fertility, sexual function, and quality of life outcomes.