In the course of last few years of my dedicated practice in Pediatric Urology and Hypospadiology, I found that anxious parents have a lot of questions and they forget to ask many of them when they are consulting me in the clinic. Here I have put down some of these question/ answers and I hope it helps the parents in participating better in the care of their little one with hypospadias
What is hypospadias?
This is a condition where the urinary opening (pee hole) is not in the correct place but located on the underneath surface of the penis. The type of hypospadias is described by where the opening is. The mildest form (glanular) is where the opening is on the glans (see diagram). In moderate hypospadias the opening comes where the glans meets the body of the penis (coronal and sub-coronal). Openings farther back (on the penis itself or at the base of the penis) are the severe varieties such as proximal penile, penoscrotal, scrotal and perineal hypospadias. In addition to the hole being in the wrong place, the foreskin is often incompletely formed on the undersurface and looks like a hood on the top. Sometimes the penis is bent downwards (chordee) usually due to tight skin but sometimes due to abnormality of the body of the penis.
Is Hypospadias common in India?
Yes. Hypospadias is one of the most common anomalies in newborn boys and it occurs to some degree in 1 in 150 to 200 boys. In India every year more than 80,000 babies are born with hypospadias.
Is Hypospadias associated with any other abnormalities?
Mild to moderate hypospadias are rarely associated with other abnormalities, so no further tests are required. If the hypospadias is very severe or there is also an undescended testis or penile size is very small, then further testing to rule out disorder of sex development or hormonal disorders is required.
Why does Hypospadias happen?
The urinary pipe called urethra normally forms from a strip of special skin folding itself into a tube on the underside of the penis. It closes up rather like a zip fastener pulling closed from the lower end to the tip of the penis. In hypospadias, for some reason the end part of the tube fails to form and remains as a flat plate. The underlying cause for hypospadias is unknown in most cases. There are several theories including increased female hormone like substances in the environment causing mild forms of hypospadias. Very occasionally hypospadias seems to run in families.
Is surgery required for all hypospadias?
Penis has two functions – urination and sexual intercourse. Mild hypospadias without chordee may not need surgery for functional reasons as these children have a straight penis and they can have normal sexual life in adulthood,and they can pass urine straight in front.
Any hypospadias with chordee needs surgery as it interferes with sexual function later. Any hypospadias beyond midpenile also needs surgery as it may impair direction of urine flow.
In our practice we have seen that some of the children develop adjustment issues due to their perception of an abnormal penis when they grow up if they are left without surgery for hypospadias. Hence, we either advise family to have the surgery done in childhood or make sure that the child receives a good support, explanation and counseling to understand if they are having any psychological issues.
What is the right age of surgery for hypospadias repair surgery?
Ideal & right age for surgery in most of the hypospadias is between 6-18 months of age. If there are any co-existing problems, then surgery may be delayed till they are sorted out. Then another window of right age for hypospadias repair surgery is between 3-5 years of age.
Why are the babies operated at such a young age? Why not wait till they are older?
Anesthesia is relatively safe after 6 months of age, that’s why we wait till that age. In infancy the babies are still in diapers, so managing them post-surgery at home is very easy for the parents. The catheter can just drip into the diapers and baby can be sent home the evening of surgery or maximum the next day. Further the skin and tissues are very pliable and heal very well at this age. Most importantly, erections and infections are also less of an issue at such a young age. Older kids have painful erections after surgery and the success rates of surgery are lower in them. Hence, right age for hypospadias surgery is in infancy.
Will there be any problem in the future regarding married life and children?
Most of isolated hypospadias once corrected do not have long-term sequences. Only cases where further investigation is warranted to look for fertility issues are where the hypospadias is very severe, there is associated undescended testis or the gender itself is in question. This can be ascertained by a set of certain investigations which your doctor will explain to you if required.
What are the usual precautions before hypospadias surgery?
Children are checked for fitness for anesthesia by a pediatrician/ anesthetist. A couple of blood tests may be required. Any history of bleeding/ blood disorder in the family should be asked. The baby should be free from any infection elsewhere (cold, cough, diarrhea, skin infections etc.). Generally, babies are kept empty stomach for 4-6 hours before surgery as it is a requirement for anesthesia. Bathing is advisable in the morning of hypospadias surgery
How long does the hypospadias surgery take?
Hypospadias Surgery time depends upon the severity of the hypospadias. Generally total time spent in the operation room (inclusive of anesthesia time) for a penile hypospadias is between 2-3 hours and may be more for severe hypospadias.
What does Hypospadias surgery involve?
Across the world and India, there are many types of operations designed to repair hypospadias. Essentially the operations we use try to bring the hole up to the correct position on the 'head' of the penis (glans), make sure that the penis is straight and repair or remove the foreskin all in one operation. Many moderate hypospadias repair operations can be done as day care procedures (in and out of hospital the same day). Sometimes the child may need to stay in hospital overnight and have a tube (stent) draining the urine for a few days. Our doctor will explain the type of surgery planned for your child.
What is a stent?
The surgeon may decide to leave a tube (stent) into the bladder to drain the urine. This is left in place for 5 to 14 days depending on the details of the operation, and usually simply drains urine into the nappy. A bag can be attached for older children who no longer use nappies. We generally prescribe antibiotics to prevent an infection in the urine.
The catheter is used to prevent urine running over the internal stitches so that in the first 24 hours there is not so much pain. When it is removed the child may still find passing urine a little painful, but this gets better in 24 hours. For bigger operations a catheter is used to keep urine from bursting through the stitches for a longer period to help healing. This catheter may irritate the bladder causing spasms, hence we routinely give antispasmodic medicines to all children after hypospadias surgery
What is the usual post-operative course after hypospadias surgery?
Children are usually allowed feeds within 3-4 hours after hypospadias surgery once they are fully awake and asking for feeds. Initially water and juices are started, if there is no vomiting gradually milk and solids are introduced. Generally, babies are on their usual diet the morning after surgery. Diaper care is taught to the parents by doctors and the nurses. Medications (syrups) are explained well and discharge to home happens by evening or morning after.
When do we have to come again to the hospital after discharge?
First follow-up visit is generally arranged within 5-7 days after surgery for removal of dressing. After removal of dressing, an antibacterial ointment is applied 4-5 times a day and at each diaper change. In distal hypospadias repair, we remove the urine pipe at this time only. Depending on the type of surgery done, second visit is arranged at 10-14 days for removal of catheter. A further checkup is done after 3-4 weeks, 3 months and at one year.
What are common problems after hypospadias surgery that we should know about?
- Most of the time the babies are slightly cranky but manageable. They feel better at home that is why we try to send them to home as soon as possible. It is also easier for the parents to manage them at home. Further a pain killer syrup is prescribed to help in pain relief.
- Babies may have intermittent spasms due to irritation by the catheter. For this reason, a small dose of bladder relaxant is usually prescribed. The dose may need to be adjusted if cramps still happen.
- Blood spotting in the diaper/ catheter may occur in the first few days. A few drops of the blood are acceptable. In case of continuing ooze, a hospital visit may be required but this is very infrequent.
- Dressing loosening up may occur in some babies, if it happens during first 2-3 days then a new dressing is placed. After that the dressing is just removed.
- Infection may happen and is the most common cause of the failure of surgery. To prevent this, broad spectrum antibiotic syrup is usually prescribed for 7-10 days. It is vital to prevent stool smearing up the dressing in immediate post-operative period.
What are the complications of Hypospadias Surgery?
These days with expert hypospadias surgeons and new techniques of hypospadias repair, the complications have become very less. Yet in 5-10% of the surgeries the result may not be optimal as penile healing is a very variable among people. The common complications of hypospadias surgery are:
- Urethral fistula – urine leaks from one of the places in the new tube
- Stenosis/ stricture- the new urethra gets tight during healing leading to pain while passing urine
- Dehiscence – the new repair completely breaks down
- Diverticulum – the new urethra balloons up leading to accumulation of urine and swelling of penis while passing urine
- Recurrent chordee- the curvature if not fully corrected can come back
About Dr A.K.Singal
Dr A.K.Singal is considered as one of the best hypospadias expert surgeons in the world. He practices in Navi Mumbai India at his hospital- Hypospadias Foundation and Mitr Hospital at Kharghar. Every year he does surgeries for almost 200 children and adults with hypospadias from more than 20 countries across the world. He is known for his best results of hypospadias surgery.