CONCORD, N.H. – Before he passed out in the medical tent in Iraq, 19-year-old Lance Cpl. James Crosby wanted to know two things: would he survive the rocket attack that sent shrapnel through his side and spine, and was he all in one piece?
"I wanted to know not just if my arms and legs were there — I wanted to know if everything else was there," he said. "You're a man, you just got blown up. What do you see when things explode? You see little pieces flying everywhere."
Crosby, now 26, joined the Marines right out of high school and had been in Iraq for 30 days when the truck he was riding was hit by a series of rockets in March 2004. Shrapnel tore up his intestines and severed a ureter, one of the tubes that carry urine from the kidney to the bladder. Left a partial paraplegic, he suffered years of painful urinary tract infections that set off excruciating nerve pain in his legs.
"They were just able to finally treat me successfully for those, not even four months ago," said Crosby, who lives in Winthrop, Mass. "I was dealing with that constantly, and the quality of life is just horrible."
Post-traumatic stress disorder and brain injuries are the signature wounds of the wars in Iraq and Afghanistan, some soldiers are also surviving with serious, debilitating injuries to the genitals or urinary system, according to the American Urological Association. The group is concerned that medical personnel may not be properly trained to handle such injuries — known collectively as urotrauma. It wants a national commission to investigate the injuries, find better treatments and design better body armor to protect against roadside bombs.
Though urotrauma isn't as readily apparent as the loss of a limb, it has far-reaching effects, including impaired sexual function, difficulty conceiving children and psychological problems. But there's insufficient data on such injuries, said Beth Kosiak, director of health policy for the urological association. Reviews of Army trauma data from the 1960s to the present did not reveal substantial information on urotrauma, she said.
New Hampshire Rep. Carol Shea-Porter has introduced a bill in Congress to create a commission, along with fellow Democrat Zach Space of Ohio and Republican Christopher Lee of New York.
"This obviously is a huge problem," Shea-Porter said. "Physically it's a problem, and emotionally it's a problem for these soldiers. So we have to work harder, and we have to pay attention to these issues. It's not one of these issues that people like to talk about, but it's very real."
Like Crosby, Former Army Maj. Anthony Smith is on constant alert for urinary tract infections. He lost a kidney, and parts of his skull, an arm and leg when he was hit but a rocket-propelled grenade in Iraq in 2004.
Though grateful for the medical care he received for his most serious injuries, he believes more attention should have been paid earlier to his urological problems.
"Because of my head injury and amputation, they didn't see the other parts," said Smith, 44, of Amorel, Ark. "I think it gets overlooked, especially if you've got other injuries."
Thanks to body armor and better care, more soldiers are surviving injuries that would have once killed them, including urological wounds. But there's little research for urologists to draw upon in diagnosing and treating complex cases.
In a study published in The Journal of Urology in 2007, researchers at the Womack Army Medical Center in North Carolina reviewed military trauma data on 2,712 trauma admissions to a U.S. Army hospital in Baghdad, Iraq, from April 2005 to February 2006. About 3 percent of patients, 76 of them, had one or more genital or urinary injuries, with explosive devices causing half the injuries. The overall urotrauma rate was similar to that of other conflicts, including Vietnam and World War II, he said.
Those wearing body armor — a Kevlar vest with ceramic plates that primarily cover the neck and upper abdomen — had a slightly lower rate of injury, researchers said. The armor includes detachable Kevlar groin protectors that hang down from the vest, giving some groin protection but it "would be of no benefit for high-velocity missiles."
The Veterans Affairs Office of Public Health tracks veterans who have left active duty in Iraq and Afghanistan and have sought medical treatment in the VA system. From July 2002 through June 2009, 12.5 percent of the 508,000 veterans who sought treatment were diagnosed with diseases or disorders of the genitourinary system, but the report doesn't specify how many of those diagnoses are related to combat injuries.
Dr. David Green, a urologist at Concord Hospital, said the few urotrauma cases he's seen involves motorcycle accidents, not bombs.
"The challenge is that in the civilian world, there is not a high incidence of these kinds of injuries. So we have a lot of young men and women now being afflicted with injuries that frankly, though we've been treating them for years, the volume hasn't been such that we know how to best treat them," he said.
He hopes the bill will lead to a better understanding of the impact of such injuries, not just in a medical or surgical sense, but in a psychological context as well.
"It's not easy to raise awareness or talk in the press about injuries to organs or areas of the body that many in the public may be uncomfortable with," he said. "It's obviously going to be pretty tough for the person who's injured. It's not something that's easy to talk about, yet for a 19- or 20-year-old to have an injury to the penis or scrotum or the vagina can be pretty darn devastating."
Smith said medication has helped him regain sexual function but his struggles along the way contributed to his divorce. Just after the blast, he heard someone looking at his injuries say "pull it off," and was terrified he'd wake up without a penis.
"When I came out, my arm was missing, my leg was missing — but that was the first thing I checked," said Smith. He has since remarried and fathered another son, his sixth child.
Though the injuries caused by roadside bombs in Iraq and Afghanistan were the main impetus for the legislation, the commission would investigate all urotrauma among active duty military and veterans resulting from a range of causes, including chemical exposure.
That's welcome news to Michael Sasser of Fayetteville, Ark., who believes chemicals he was exposed to aboard a Navy aircraft carrier in 1968 caused the "nonspecific urethritis" he battled off and on for more than a decade after leaving the service.
"This legislation is necessary, especially for the soldiers over there now," he said.