While at many trauma centers there is significant overlap and redundancy between urologists and general trauma surgeons in the management of traumatic injuries of the bladder and upper urinary tract, injuries to the external genitalia and urethra remain uniquely the domain of the urologist. Initial management of these injuries often requires complex decision-making and technical prowess. Furthermore, surgeons must balance the urgency of the acute injury with the patience required to ensure the best long-term outcome for the patient. As a significant number of these injuries occur in young men, urologists are additionally faced with considering the lasting impact that these injuries can have on fertility, sexual function, self-esteem, and overall quality of life.

In this year’s AUA2023 plenary panel on the acute management of external genital and urethral trauma, we focused on discussing complex trauma cases and the difficult decisions involved in the management of these patients. Primarily, we focused on the lasting impacts that these injuries and our management choices can have on a patient’s quality of life. With the guidance of an expert panel of reconstructive urologists composed of Dr Sarah Faris from University of Chicago, Dr Cooper Benson from University of Texas at Houston, and Dr Andrew Cohen from the Johns Hopkins University, we explored 3 unique and complex urogenital trauma cases to highlight the importance of considering both the acute and the ongoing care of these patients.

Presenting a case of a patient who sustained a gunshot wound to the penile urethra, Dr Faris highlighted how patients with injuries to the anterior urethra with significant tissue loss can undergo planned staged urethral repair, rather than attempting definitive repair at the time of injury in a contaminated and limited field. She showed how marsupialization of the remaining urethral mucosa to the penile skin prepared her patient for a Johanson-style repair with retubularization of the neourethra a few months later (Figure 1). Dr Cohen then discussed the acute management of a pelvic fracture urethral injury in a young 24-year-old man with a suprapubic tube and delayed urethroplasty (Figure 2). Despite an excellent anatomical outcome from his urethroplasty, this patient was still faced with fertility and erectile dysfunction concerns following his injury. And lastly, Dr Benson showed the extensive damage and morbidity genital and perineal burns can have and the tremendous work and dedication it takes to slowly and deliberately rebuild skin coverage following these injuries (Figure 3).

While genital trauma as a rule is heterogeneous and can be the result of a multitude of mechanisms with variable degrees of tissue loss, the AUA Urotrauma Guidelines published in 2014 provide an excellent framework for managing these difficult injuries.¹ In conjunction with these guidelines, this year’s plenary was designed to aid urological surgeons in understanding the importance of acute triage and prioritization of life-threatening injuries, while also implementing damage control maneuvers that optimize opportunities to definitively repair genital injuries in either an early or delayed setting. Evaluating injuries ranging from burns to blunt injuries to gunshot wounds, this session highlighted how urologists treating these injuries need to be prepared to utilize a multitude of tools from their reconstructive toolboxes to manage diverse injury patterns.

These cases served as excellent examples that highlight the significance of the long-term care these patients often require. Notably, the AUA Urotrauma Guidelines specifically contain a statement emphasizing the important role of incorporating ancillary services such as psychological and reproductive counseling for individuals who experience significant loss of sexual or reproductive function. Thus, it is important to remember as treating physicians that seemingly small alterations in urinary and sexual function, as well as fertility, can have significant negative impacts on these patients long after they have recovered from their acute injuries. As such, and as emphasized by our expert panel, it is vitally important to consider the long-term implications of these injuries and our chosen management strategies in the context of the anatomic, functional, and psychosocial impacts.