Hypospadias

Hypospadias is a birth disorder where the urinary opening (pee hole) is located on the undersurface of the penis instead of at the tip of penis. Hypospadias may be of varying severity depending on where the opening is. In the mildest form (glanular hypospadias) is on the glans slightly short of tip. In moderate hypospadias, the opening is where the glans meets the body of the penis (coronal and sub-coronal). Urinary openings farther back (on the penis itself or at the base of the penis) are so called the severe varieties. In addition to the hole being in the wrong place, the foreskin is often incomplete on the undersurface and looks like a hood on the top. In severe cases, the penis is bent downwards (chordee) usually due to tight skin or sometimes due to abnormality of the body of the penis.

Incidence & other factor

Hypospadias occurs to some degree in 1 in 150 to 200 boys. In India every year more than 75000 babies are born with hypospadias and need to see a pediatric urologist. Mild to moderate hypospadias are generally not associated with other abnormalities so further tests are not required. If the hypospadias is of severe variety or an undescended testis or the penis is small, then further testing is required.

Etiology & pathogenesis

The urinary pipe within penis (called urethra) normally forms from a strip of special skin forming itself into a tube on the underside of the penis. It closes up like a zip fastener from the back end to the tip of the penis. For some reason, in children with hypospadias the last part of the tube fails to form and it remains incomplete. The underlying cause is not known in most cases. There are several theories including increased hormone disruptors which are female hormone like substances causing mild forms of hypospadias. Very occasionally it seems to run in families.

Role of Surgery

Surgery may be required for 2 reasons:
a) To make everything work properly, i.e. to make the urine comes out straight and to make the penis straight.
b) For cosmetic reasons.
If the boy can pass urine forwards and the penis is straight then the operation is purely cosmetic. Untreated hypospadias can lead to psychological disturbances. Surgery is best done in the first year of life.

Ideal age for Hypospadias repair (Urethroplasty)

Ideal age for surgery in most of the hypospadias is between 6-12 months of age. If there are any co-existing problems then surgery may be delayed till they are sorted out.
Anesthesia is relatively safe in children after 6 months of age, that’s why it is better to wait till that age. In infancy the babies are still in diapers, so postoperative management is very easy at hoe by the parents. The catheter is left to just drip into the diapers and baby can be sent home the evening of surgery or maximum the next day. Also, penile skin and tissues are very soft and heal very well at young age. Most importantly, erections and infections are less of an issue at such a young age.

Precautions before surgery

Babies 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 checked. The baby should be free from infection elsewhere (cold, cough, diarrhea, skin infections etc.). Before surgery, babies are kept empty stomach for 4-6 hours as it is a requirement for anesthesia. Bathing is advisable in the morning of surgery.

Type & details of Surgery (Urethroplasty)

Surgery time depends upon the type of the hypospadias. Generally total time spent in the operation room (inclusive of anesthesia time) for a hypospadias is between 2-3 hours and this may go upto 4-5 hours for severe hypospadias
There are many types of operations designed to repair hypospadias. Essentially the operations bring the hole up to the correct position on the ‘head’ of the penis (glans), make sure that the penis is straight and looks just like a circumcised penis 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. There will be a tube (stent) draining the urine for a few days. Further details are explained by our doctor before the child is planned for surgery.

Use of Stent/ Catheter for drainage

At the end of surgery, a tube (stent) is left into the bladder to drain the urine. This is left in place for 5 to 14 days depending on the type of the operation, and simply drains urine into the nappy. A bag can be attached for older children who no longer use nappies.
The catheter is used to prevent pain of passing urine through the recently operated urethra. For a major urethroplasty, catheter may be kept for a longer period to help healing. This catheter may irritate the bladder causing spasms in some cases. The baby will be cranky and irritable at time of spasms. If spasms occur, they can be easily treated by giving a medicine.

Post-operative course & Follow-up

Babies are usually allowed feeds within 3-4 hours after surgery once they are fully awake and looking for feeds. Initially liquids such as water and juices are started if there is no vomiting gradually solids are introduced. Generally, babies are on their usual complete diet the morning after surgery. Double Diapers are used by parents to ease the postoperative care. Medications (syrups) are explained well and discharge happens by evening or morning after.

First follow-up visit is generally after 5-7 days after surgery for removal of dressing. After removal of dressing, an antibacterial ointment is applied 4-5 times a day and also each diaper change. Depending on the type of surgery done, second visit is arranged after 10-14 days for removal of catheter. A further check-up is done after 3-4 weeks, 3 months and at one year.

Common problems after surgery

➾ Most of the time the babies are slightly cranky but manageable with medicines. 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.
➾ Babies may have intermittent bladder spasms due to irritation by the catheter. For this reason a small dose of bladder relaxant medication 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 bleeding, 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 may just be removed.
➾ Infection may happen and may be most common cause of the failure of surgery. To prevent this, broad spectrum antibiotic syrup is usually prescribed for 7-10 days

Prognosis and long term outcomes

Isolated hypospadias once corrected does not have long-term sequences. Only cases where the hypospadias is very severe or there is associated undescended testis or the gender itself is in question. This can be ascertained by a set of certain investigations which doctors will explain if required.