What Is Hypospadias?
Hypospadias is a birth defect of the penis. The opening of the urethra is not at the tip of the penis, but somewhere along the underside or to one side. The opening of the urethra can be very small or it could be missing entirely.
If there is no opening at all, then urine will not be able to pass through the penis and will come out of a hole in the baby’s scrotum instead. In mild cases, a baby may have an opening in his penis that is higher up than normal (high-lying meatus).
Signs and Symptoms of Hypospadias
It is usually an asymptomatic condition at birth, but some cases manifest at around 1-2 months. Most children with hypospadias have no symptoms and are unaware that they have it. In some cases, however, there may be mild pain or a discharge from the penis (such as from an infection). These symptoms should be treated immediately and reported to your physician if they persist for more than a few days or worsen significantly.
- Nearly all patients with hypospadias have only a partial foreskin that makes the penis look neither natural nor circumcised.
- Opening of the urethra at a location other than the tip of the penis
- Downwardcurve (bending)ofthe penis known as (chordee)
- Hooded appearance of the penis because only the top half of the penis is covered by foreskin
- Abnormal spraying during urination
- A penis is downward when erect
- A hole in the penis or urethra
Hypospadias is present at birth (congenital). The exact reason this defect occurs is unknown. Sometimes hypospadias is inherited.
As the penis develops in a male fetus, certain hormones stimulate the formation of the urethra and foreskin. Hypospadias results when a malfunction occurs in the action of these hormones, causing the urethra to develop abnormally.
Though the cause of hypospadias is unknown, both environmental and genetic factors have been associated with the condition, including:
This condition is more common in infants with a family history of hypospadias.>
Maternal age over 40:
Some research suggests that there may be an increased risk of hypospadias in infant males born to women of an advanced age.
Exposure to smoking and chemicals:
There is some speculation about an association between a mother’s exposure to pesticides and hypospadias, but further studies are needed to confirm this.
Pregnant women can reduce the risk of hypospadias and other birth defects by practicing healthy behaviors, including:
- Not smoking or drinking alcohol
- Staying at a healthy weight
- Taking 400 to 800 micrograms (mcg) of folic acid a day
- Seeing the doctor regularly while pregnant
The rate of hypospadias appears to be rising in Western cultures. One theory for this increase is the use of environmental pollutants, especially hormone-like compounds that are used in pesticides on fruits and vegetables
Associations of hypospadias
In some boys, especially those with proximal hypospadias, the penis is bent downwards to such an extent that sexual activity can be impaired as an adult. Boys with proximal hypospadias may also have a condition called penoscrotal transposition, where the scrotum is located around the penis instead of below it. All of these issues can be corrected.
Signs and symptoms of hypospadias may include:
- Most boys with hypospadias do not have other major medical problems.
- Occasionally, one or both of the testicles may not be located in the scrotum.
- If hypospadias and cryptorchidism (abnormal testis position) occur together, we may recommend additional testing.
Downward bending of the penis (A). The typical partial foreskin found on the top of the penis, often called a hooded foreskin, does not wrap around to cover the underside of the penis in most boys with hypospadias (B). Penoscrotal transposition often occurs in boys with proximal hypospadias (C)
Hypospadias is commonly diagnosed through a physical examination. Due to its common occurrence, hypospadias is routinely checked by doctors after birth. It may also be seen at time of or after circumcision in some patients
Hypospadias Discovered After /At time of Circumcision
One type of hypospadias occurs with a normal foreskin and so it is not discovered until after circumcision, or later in childhood when the foreskin retracts in boys who are not circumcised. This type of concealed hypospadias is often referred to as MIP, which stands for Megameatus with Intact Prepuce. Although circumcision is usually postponed until the time of hypospadias repair in boys with a partial foreskin, removal of the foreskin in those with concealed MIP hypospadias does not make repair of the urinary opening more difficult. It is important to emphasize these boys have a birth defect and not an injury during circumcision A boy with normal foreskin is found to have a concealed hypospadias when the foreskin is pulled back (A,B). When this is discovered at the time of newborn circumcision, the circumcision can be completed without making later hypospadias repair more difficult. If it is discovered in an uncircumcised boy when the foreskin becomes retractable, the hypospadias can be repaired along with a circumcision, or by saving the foreskin, whichever the family prefers.
When to see a doctor?
Most babies are diagnosed with hypospadias after birth while still in the hospital.
-If your child has had surgery and the fever persists for less than a week, or is over 101°F (38.3°C) in the week after surgery, call your provider immediately.
-If they have increased swelling around their catheter site, pain with urination, drainage from it that is not urine related or bleeding from it more than usual during typical activities – these are signs to contact the provider right away as well.
-Also if there was an increase of throwing up 3 times and cannot keep fluids down or no diaper change since last visit even if you think “it still looks wet” which can be the indication of bladder blockage.
How is hypospadias treated?
Surgery is the only option for correction in majority of patients. Mild forms of hypospadias may not require any intervention. If a hypospadias is more severe, surgical correction may be recommended. If left unrepaired, the following complications may occur as the child grows and matures:
Complications of Unrepaired:
- The urine stream may be abnormal:
- The penis may curve as your baby grows causing sexual dysfunction later in life
- If the urethral opening is close to the scrotum or perineum, the child may have problems with fertility later in life.
Specific treatment for hypospadias will be determined by your baby’s health provider based on:
- The child’s gestational age, overall health and medical history.
- The extent of the condition.
- The baby’s tolerance for specific medications, procedures or therapies.
- Expectations for the course of the condition.
- The family’s opinion or preference.
Testosterone before Surgery
We do not recommend preoperative testosterone treatments. These have been used to grow the penis larger and to possibly increase blood flow to the skin. However, our studies have shown that results of surgery are not improved by testosterone. In fact, preoperative treatment with testosterone may increase complications and sometimes causes side effects such as aggressive behavior and pubic hair in infants and children
Hypospadias is fixed with surgery. Surgeons have been correcting hypospadias since the late 1800s. More than 200 types of operations have been described. But since the modern era of hypospadias reconstruction began in the 1980s, only a handful of techniques have been used by surgeon.
he goal of any type of hypospadias surgery is to make a normal, straight penis with a urinary channel that ends at or near the tip. The operation mostly involves 4 steps:
- straightening the shaft
- making the urinary channel
- positioning the meatus in the head of the penis
- circumcising or reconstructing the foreskin
Age of surgery
- If the hypospadias needs surgical repair, it is usually done when the baby is between 6 &24 months, when penile growth is minimal.
- At birth, the child should not be able to undergo circumcision, as the extra foreskin may be needed for the surgical repair.
- The surgical repair can usually be done on an outpatient basis (and may require multiple surgeries depending on the severity).
- Not much tests are required before hypospadias surgery, usually complete blood count is only required is most case
- There must be noevidence of infection, other illness and any familial disorders.
- A pediatrician consult is often taken for a systemic examination.
- If the child has infection at any other site in body such as cold, cough, fever, diarrhea, skin infection – it is better to postpone the surgery till the infection is clear.
- Family history is taken for any bleeding disorder or any drug allergies.
If the examination and the tests are normal, then hypospadias surgeon and family can fix up a date
The child needs to be empty stomach for atleast 4 hours for breast milk and 6 hours for other milk/ solid foods/ breads on the day of surgery before surgery. This is a mandatory safety precaution to prevent vomiting during anesthesia. Keeping a 6 months or a one year old child hungry for 4 hours is not an easy task. Infact some of the parents are more worried about keeping a young child hungry than the actual surgery but this is something which is non-negotiable. Often we give the child light sedative syrup 1-2 hours before surgery to help the baby sleep.
The child can be given a bath on the morning of hypospadias repair operation as it will be difficult to give a formal head to toe bath for next 5-7 days after surgery.
Some of the children may be a little constipated, we advise parents to give a glycerine suppository or a laxative the night before so that the child passes stools and has an empty bowel. Post hypospadias surgery, local pain can often worsen constipation. Hence, do tell your doctor beforehand so that a mild laxative can be prescribed at tie of discharge.
In a hospital with daycare facility, we prefer to admit the child for hypospadias surgery early morning at 6:30am -7am. If the parents live farther away from the hospital or the hospital doesn’t have a daycare facility, we like to admit the children the night before surgery.
There are more than 200 ways to do the hypospadias repair and the best is Pictures
- 1 tip repair
- 2. stag repair
Before hypospadias surgery is started, family has to fill up an anesthesia and a surgery consent form which is quite detailed in general. Sometimes the parents get alarmed on seeing the form. But please feel free to ask us about any doubts which you have. We always have the best of intentions and make all efforts to get your baby back home safely after hypospadias surgery.
Children are provided and changed into hospital clothes appropriate for their age on the morning of hypospadias surgery. Team and parents must make sure that the iv canula is inserted after changing of clothes else with the canula and splint attached, it is difficult to change clothes.
If the child is irritable while staying hungry we either advise a pacifier or a light sedative syrup till the time of anesthesia.
Crying child is not a good sight just before hypospadias surgery for the parents or the hypospadias doctor. If the child has an iv line, anesthesia team often administers a small dose of premedication to help sedate (make the child sleep) the child before shifting to operation theatre. We must understand that getting the child with hypospadias fully cured is a team effort and it needs devotion and patience from both the family as well the surgical team.
The complication rate in boys with distal hypospadias repair is less than 1 in 10. Problems happen more often after a proximal correction.
TThe most common problem after surgery is a hole (“fistula”) forming in another place on the penis. This is from a new path forming from the urethra to the skin. Scars can also form in the channel or the urethral opening. These scars can interfere with passing urine. If your child complains of urine leaking from a second hole or a slow urinary stream after hypospadias repair, he should see his pediatric urologist.
TMost complications appear within the first few months after surgery. But fistulas or blocks might not be found for many years. Most problems are easily fixed with surgery after the tissues have healed from the first operation (often at least 6 months).
TIt’s not easy to think about more surgery in these unusual cases. But there are options that offer hope for success. Unhealthy scarred tissues from prior operations can be removed and replaced with fresh tissue from another part of the body (most often from inside the cheek). This can create a working urinary channel and still look normal. If your pediatric urologist hasn’t used these techniques, he/she will direct you to a center where they’re used.
Check-ups after Surgery
TMany pediatric urologists believe that routine office check-ups aren’t needed after the first few months because the risk for problems past then is so low. Others think boys should be seen throughout childhood until after puberty. You and your son’s health care provider will decide what’s best.
Tests and diagnosis
Hypospadias is a birth defect in which a male fetus’ urethra is positioned on the underside of the penis instead of at the tip. It is caused by a problem that occurs during the formation of the urethra. This problem prevents normal development of the penis during fetal development. It can cause various problems, such as an inability to urinate standing up or urinating while standing up, difficulty with sexual intercourse, or erectile dysfunction.
If left untreated, hypospadias can lead to other complications such as penile curvature or curvature of other genital organs (such as the scrotum), and these may result in pain or discomfort when sexually stimulated and may affect sexual function.