Authors: Mary Roach
“Also,” says Jezior, “the mouth is tolerant of pee.” He means that the mouth is built for moisture. It’s possible to create a urethra from hairless skin on the underside of the forearm or behind the ear, but the frequent wetting from urine can degrade it. A kind of internal diaper rash may ensue. Inflammation eats away at the tissue, tunneling an alternate path for the waste, called a fistula. Now you are dribbling tinkle from a raw hole in your skin. Just what you need.
White’s face has been draped with a blue sterile cloth with a single opening, reminiscent of an Afghan burqa. In this case, the opening is positioned over the mouth, not the eyes, as though the patient belonged to some esoteric spin-off sect. Retractors square White’s mouth, pulling it wide to either side, the way kids will do with their fingers to frame a stuck-out tongue. Jezior outlines the graft with a surgical marker and uses an electrocauterizing tool to cut it free. A vaguely familiar aroma, somewhere between brazier and burning hair, hits the air. Jezior is indifferent to it but reveals that the prostate, when cut open, releases a distinctive scent that’s kind of nice.
Using long-handled forceps, Jezior passes the dangling tissue to Molly. They look like a couple sharing a Chinese entrée. Molly drapes the graft over one gloved thumb and, with her other hand, snips away bits of fat and tissue to make it thinner. It takes time for new blood vessels to grow in and service a graft. For the first couple of days, the cells of the graft are nourished by a broth of serum. If the graft is too thick, only the cells on the surface will thrive, and those on the interior will die. For this reason, larger skin grafts, like the ones on the back of White’s remaining leg, are run through a mesher. The holes of the mesh create more surface area for the business interactions of cellular life: nutrients in, waste out.
If replacing part of the urethra doesn’t resolve the problem, another option would be perineal urethrostomy. Here the surgeon would excise the damaged portion and thread the shortened urethra through an opening in the perineum—the no-man’s-land between scrotum and rectum. “Then they have to sit to urinate, like ladies do,” says Molly.
How big of a deal is that? Jezior makes the point that someone whose reproductive organs have been damaged by an IED has typically also lost one or more limbs. Having to sit down to urinate probably doesn’t rank high on the worry list.
Molly tilts her head to face me. “It’s huge.” Depending, to some extent, on culture. Some years back, she attended a session on perineal urethrostomy at an international urology conference. The Italian surgeons were aghast. “You can’t tell an Italian man he’s going to have to pee sitting down.”
Molly was one of two female urologists at the meeting. She notices the disparity, but it doesn’t faze her. On the upside, she never waits for a toilet during session breaks. “I’ve been the only one in the women’s room at some of these urology conventions.”
“Same here,” deadpans Jezior.
The piece of cheek is ready to begin its new career. A nurse pulls a sterile drape from White’s hips and begins rubbing his skin with the antiseptic wand. Such is the vigor of the youthful male that even under general anesthesia, even when it’s a ChloraPrep sponge bestowing the caress, the penis responds. It is a less robust response than normal, perhaps, because Jezior has prescribed something to temporarily blunt erections. Surgical incisions are sewn up while the organ is flaccid; erections stretch the incision. They
hurt
. However, erections bring more blood into the penis, which speeds healing, and they also help prevent scarring. The latter is important because scarring—especially in erectile tissue—can make erections crooked and uncomfortable. For this reason, sexual activity is sometimes encouraged postoperatively as a kind of physical therapy for the penis. Walter Reed nurse manager Christine DesLauriers, whom we’ll shortly meet, convinced the intensive care unit staff to establish a daily “intimate hour,” during which no medical staff would visit the patient’s room, just spouses and partners.
Jezior opens the organ to access the urethra. As he works, he rests the heel of one hand on White’s scrotum, using it like a tiny beanbag chair. Molly’s style is more formal; she holds her instruments like a knife and fork, wrists raised. The rectangular graft is stitched in place but left flat. Urine is temporarily diverted through an opening made in the skin below the graft. In a follow-up operation, once a new blood supply grows in and it’s clear the graft has taken, Jezior will go back in and hook up the waterworks. He’ll roll the graft into a tube and connect it to the original urethra, and that, one hopes, will be that.
When it’s over, Jezior snaps off his gloves and walks directly to a phone on a desk in the corner of the operating room and punches an extension. White’s mother is waiting in his hospital room. “He’s awake, and everything went well.”
F
OR THE
third time today, I’ve lost Dr. Jezior. I’ll bend down to slip on some surgical shoe covers or step away to use a drinking fountain, and when I turn back he’s gone: pulled away by a nurse, an administrator, a patient’s wife. He never says no, although he has every reason to. Chronically over-busy, he moves through the halls at a slight forward cant, as if arriving a second sooner might give him a jump on the enduring backlog of things that need doing. The stack of reading material in his office bathroom, all of it urological, threatens to collapse the sink.
Like a lost child in a mall, I know to stay put and eventually he’ll come for me. I browse some information on “Boxes and Storage,” one of the many themed bulletin boards that line the corridors of Walter Reed. “Mature Indian wheat moth larvae pupating in corrugated cardboard,” says a photo caption. It’s the most unsettling image I’ve seen all day, but not for long. Jezior and I are headed to his office so he can show me photographs of some of his patients in Iraq. Not to unsettle me, but to give me a broader sense of what bullets and bombs, and then surgeons, can do.
Jezior narrates with simple anatomical vocabulary, but I can’t always parse what I’m seeing in a way that matches the words. I can’t even see
person
in some of these images. I see
butcher shop
. Bandages protect the psyche, too; some of these soldiers never saw what I’m seeing. Jezior had a patient who didn’t see the injuries to his penis for three weeks. He clicks ahead to a slide from this man’s arrival at the hospital, a close-up of the weapon-target interaction, as they say in ballistics circles. How do you prepare a patient like this for the unveiling? “We used to try to sound optimistic,” Jezior says. “But when this guy finally saw it, he was like, ‘Oh, my God.’ It was another devastation, a second loss.” Now they’re blunter. “I’ll say, ‘It’s a severe injury. You’ll have to see it.’” If there’s going to be a surprise, let it be a positive one.
What can be done for these men? A lot. The art of phalloplasty—crafting a working penis from other parts of a patient’s body—has come a long way (thanks in no small part to the transgender community). To build a penis, Jezior begins with an arm. A rectangular flap of skin on the underside of the forearm is planed into two thinner layers. The inner one is rolled to form a urethra; the outer becomes the shaft. This tube within a tube is left in place, nourished by the arm’s blood supply. When what remains of the original organ heals, the new model is detached from the arm and reattached farther south.
Erectile tissue is the challenge. While spongiform erectile tissue exists in other parts of the male anatomy—along the urethra and in the sinus cavity (congestion being an erection of the nasal turbinates)—there isn’t much of it, and no one has tried to transplant it. And while there are eye banks and sperm banks and brain banks, no one is banking noses. So in place of the corpora cavernosa—the two parallel cylinders of erectile tissue—surgeons install a pair of inflatable silicone implants. (To get erect, the patient—or his friend—squeezes a little silicone bulb implanted in the scrotum that pumps saline from a receptacle in the bladder.) Hook up the tubes and let the nerves regrow, and in time orgasm and ejaculation are back on track.
Jezior continues with his slides. “This is a brigade commander. A sniper shot him across the top of the groin. Took out the middle part of his penis.” Losing the whole penis—and surviving the blast—is rare. Among Grade 3 and higher (the worst) cases of Dismounted Complex Blast Injury, 20 percent suffer damage to the penis, but only 4 percent lose everything.
You have to wonder: Was the sniper off his game, or was the shot intentional? Are there some who aim for the crotch? Jezior thinks that there are. He’s heard stories from World War II. Dale C. Smith, a professor of military medicine and history at the nearby Uniformed Services University of the Health Sciences (USUHS), has also heard those stories, but knows of no evidence to back them up. Smith points out that the secondary goal of a sniper is to sow fear. In that sense, the crotch is an effective shot. However, Smith said in an email, it is also a risky shot, in that a sniper is looking for a “high percentage return” on the tactical effort and risk of getting into position. The pelvis is not considered a “kill shot.”
Another gunshot case follows, this one through the scrotum and rectum. “This is half his anus here. Here’s his scrotum up here. This is the insides of the testes. ” The horrid Cubism of modern warfare. The reconstruction in this case was done by Rob Dean, Walter Reed’s director of andrology. The andrologist’s beat is reproduction, not excretion: testes and scrotums, hormones and fertility. Dean is joining Jezior and me in a few minutes for lunch, in a sandwich place downstairs. The two served four months together in Iraq.
Jezior closes the photo file and leads me out through the urology waiting area, toward the stairs. “Patient Jackson?” calls a receptionist. As though “patient” were the man’s rank. I guess in a sense it is. He may be a major or a colonel and the man across from him may be a private, but here everyone’s a patient. In a culture defined by rank and hierarchy, Walter Reed can seem—to an outsider, anyway—endearingly egalitarian.
Dean is already in the line to order sandwiches. He, too, is extremely busy, which, in the grand and ghastly scheme of war, is a good thing. It means more men are surviving bigger explosions. If funding and research lag behind, it’s partly because of the general cultural discomfort that surrounds all things sexual—including the poor organs themselves. On a much simpler level, Jezior says, it’s a case of out of sight, out of mind. “When some celebrity comes to Walter Reed and visits you in your room . . .”
Dean jumps in. They finish each other’s thoughts like an old married couple. “. . . Right, the President doesn’t pull down the sheet and go . . .”
“. . . ‘That’s terrible, look at that. His penis is gone. Let’s get some money flowing for that.’”
Walter Reed Medical Center pays for phalloplasty, although there was initially some resistance. (The implants alone cost about $10,000.) Erections were thought of as “icing on the cake,” Dean says. “They’d say, ‘Oh, people don’t really need that.’ I’m like, ‘Well, the guy with the amputated legs doesn’t
need
prostheses. Put him in a wheelchair!’ And they’d go, ‘Oh, no! It’s important that they walk!’ I’d say, ‘Okay, well, most people think it’s important to have sex.’ Can I get a Caprese sandwich and a Coke Zero?”
Dean has expressive hands and eyes and prominent arching eyebrows, and when he talks and laughs, the whole lot of them join the fun. In this business, humor and candor are a therapy on their own. Dean has been known to put a ruler to a discouraged patient’s penis and hoot, “You’ve got six inches! How much more do you need?”
Don’t be fooled by the jolly tone. Dean is a bulldog for his patients. He was a force behind the push to get the VA to cover in vitro fertilization for soldiers whose injuries left them sterile. He gives talks to USUHS students about sexual health issues among injured service members and answers questions at veterans support groups. He helped colleague Christine DesLauriers found the Walter Reed Sexual Health and Intimacy Workgroup: a dozen-plus local medical providers and social workers who gather periodically to plot strategy and share resources. For instance:
Sex and Intimacy for Wounded Veterans
, a book by DC-area occupational therapists Kathryn Ellis and Caitlin Dennison. These two do not flinch. Here are sexual positioning tips for triple amputees. Ways to modify a vibrator for a patient who’s lost both arms below the elbow. I second the sentiments of the title page endorsement (if not the precise phrasing): “We should put a copy of this manual in the hands of every patient, spouse, and medical provider . . .”
Especially the medical providers. “It’s amazing,” says DesLauriers, “how many of them are frightened to bring it up.” She told me about a Marine she’d worked with who said to her, “Christine, I’ve had thirty-six surgeries on my penis, I’ve had my shaft completely reconstructed, and not one damn person told me how I’m going to go home and use the thing on my wife.”
Few talk to the wives, either. “It’s depressing watching some of them interact,” says Jezior. “In your mind you’re going, ‘She’s going to leave him.’” When I asked DesLauriers what the divorce rate is, she said, “Divorce rate? How about suicide rate. And what a shame to lose them after they’ve made it back. We keep them alive, but we don’t teach them how to live.” Walter Reed has no full-time sex educators or sex therapists on its payroll. The Internal Medicine Clinic offers appointments in “sexual health and intimacy,” but only one nurse is set up to handle them.
“It’s not,” Jezior says when the topic comes up, “as well situated as we’d like it to be . . .”
Dean cuts through it. “There’s nothing. There’s a vacuum.”
DesLauriers’ workgroup has spent seven years meeting with military boards, trying to get Defense Department funding for an on-staff sex therapist at Walter Reed. She gets lots of support, almost entirely verbal. The problem isn’t just budget cuts. “The problem is getting the US government to embrace sex.” She told me about a meeting several years ago with an admiral who headed up Walter Reed. “He said, ‘I don’t understand what we are teaching someone who doesn’t have a penis. What exactly are you going to help that person with?’”