Hypospadias
Hypospadias (sometimes misspelled as hypospadius) is a condition in which the end of the urethra (the tube in the penis through which urine passes out of the body) is not located at the tip of the penis. The condition occurs in approximately 1 out of 200 newborns. The cause of this condition is not known and is usually an isolated congenital defect that is not associated with any other defects in other organs.
In more than two-thirds of cases, the defect is located near the end of the penis where the abnormal opening is located either within the glans (the "head" of the penis) or just below the glans on the underside of the penile shaft. In more severe forms of hypospadias, the opening is located further down on the penile shaft or in the scrotum. Hypospadias is also associated with penile curvature in which the penis curves in a downward direction. This is known as "chordee." In general, the more severe the hypospadiac defect, the more severe the chordee.
Usually, hypospadias is associated with an incomplete foreskin such that this condition is usually recognized when a newborn is examined. However, in some cases, hypospadias can occur with a full foreskin and is only recognized at the time a circumcision is being performed or after the circumcision has been completed.
Why do children with hypospadias require surgery?
Surgery for hypospadias is done for functional reasons, as well as cosmetic and potential psychosocial concerns.
- The two major functional reasons to perform surgery are the downward deflection of the urinary stream that results from the abnormal location of the urethral opening, and potential sexual dysfunction later in life related to the downward curvature of the penis.
- Cosmetic concerns are closely linked to potential psychosocial repercussions related to the abnormal appearance of the penis and the child's perception of his genitalia later in life.
Not all cases of hypospadias require correction. In minor cases where there is no identifiable functional deficit and/or an absence of any cosmetic concerns, one may consider not performing surgical correction.
What type of surgery is performed for hypospadias?
In most routine cases of hypospadias where the opening is located near or within the glans, the opening defect and associated chordee can be corrected in a one-stage operation on an outpatient basis. However, in more severe cases, two and sometimes three or more surgeries may be needed. Surgery is usually undertaken prior to one year of age at 6 to 12 months of age.
The goals of hypospadias surgery are:
- To advance the opening of the urethra to the tip of the penis which requires the creation of new urethral tube (this is usually done with skin from the penis and/or foreskin)
- To correct the penile curvature
- And to cosmetically achieve a normal appearing penis.
While there are many different surgical techniques to fix hypospadias, recent advances in this type of surgery have made it more successful than in the past. In cases where the opening is located near or within the glans, the initial one-stage surgery is successful in more than 90% of cases, and no additional surgery is expected to be necessary for the remainder of the individual's life. In cases that fail, repeat surgery maybe necessary. In more severe cases where two or more surgeries are planned, overall success rates are lower.
In some cases, your surgeon may elect to pretreat your child with male hormone treatments (topical cream or shots) that temporarily enlarge the penis and enhance its blood supply. These temporary changes enhance the ability to achieve a successful surgical result. The use of this preoperative hormone treatment is reversible and has been shown to be safe. The specific aspects of your child's hypospadias surgery, what to expect after surgery, expected success rates, and the potential complications should be discussed in detail with your pediatric urologist.
Basic care after surgery
(Note: Each doctor may have slightly different post-operative instructions based on your child's needs; always follow those instructions.)
The dressing and bathing instructions
The dressing typically stays on for about 4 days; during that time, do not immerse the baby; sponge baths only. On the fourth day, soak the child in a warm bath for 20 minutes, which in most cases causes the dressing to fall off. If it does not, re-soak two to three times/day. The penis will be quite swollen and bruised when the dressing comes off; this is normal. There may also be some mild bleeding which can be controlled with gentle pressure. You will also notice several stitches around the penis that will dissolve within six to eight weeks. Following removal of the dressing, bathe the child two times a day and apply antibiotic ointment (Bacitracin, Neosporin, or Triple Antibiotic) liberally. If there's a stent (a small tube) in place Some patients will have a stent in the urethra following the repair. It is sewn to the head of the penis with two small absorbable stitches. The stent will usually fall out on its own when these stitches separate. This usually occurs by the 10th day after surgery. If it does not, please call the office to have it removed. It is OK to have a portion of the stitch remaining after the stent is removed; the stitch will eventually dissolve.
Medication
- Tylenol with Codeine as prescribed for pain on the day of surgery. Plain Tylenol thereafter. (Note: Tylenol with codeine may cause constipation. For help with regular bowel movements, offer the child apple juice, apple sauce or prune juice. If constipation continues, use a glycerin suppository, which is available without a prescription.)
- Antibiotic as prescribed. Continue use of antibiotic until two days after the stent comes out.
- Ditropan (oxybutinin) as prescribed for bladder spasms while the stent is in place. (Note: Children may get constipated and red face with this medication.)
- Vitamin C, as directed, as to aid in healing.
- Antibiotic ointment as noted above; apply to penis with each diaper change.
Call your doctor if:
- There is persistent bleeding from the site of surgery.
- If the child gets a temperature greater than 102F.
- If there is pus-like or foul-smelling drainage from the wound.
- If the penis or urine has a foul smell.
- If the child does not urinate for 4 to 8 hours after the stent falls out or is removed.
Don't forget a follow-up appointment! Please make sure you have a check-up appointment approximately two to three weeks after surgery.