Hypospadias is usually classified according to the location of the opening. As the defect increases in severity, the opening to the penis will be found further back on the penis. The most severe types can have openings at the region of the scrotum and even in the perineum (the region between the anus and scrotum).
Hypospadias can be associated with another defect called chordee. Chordee is a downward curvature of the penis. Both hypospadias and chordee must be repaired so that a child can have normal urinary and reproductive health.
As a boy is developing in utero, the penis begins to form in the sixth week of fetal life. Two folds of tissue join each other in the middle and a hollow tube is formed in the middle of the future penis. This tube is the urethra and its opening is called the penile meatus. As the skin folds develop to form the penis, any interruption in this process leads to the meatus being located in a location further from the end of the penis. The exact etiology for this premature cessation of urethral formation is poorly understood. In addition, the etiology of the often-associated abnormal downward curvature (chordee) is also poorly understood.
Reasons to Treat
Hypospadias is repaired through a surgical procedure. When the repair is performed, the urethra is extended to the tip of the penis to its normal location. In addition, any bend is straightened. This is important for many reasons. When the opening is too ventral (underside), a male is unable to stand and urinate like other boys. It is harmful to a boy's normal social development to have to sit while he urinates. Additionally, a straight phallus is essential for normal reproductive health and sexual function.
The treatment of hypospadias is always surgical. Initially when the child is born and hypospadias is identified, it is important to delay any thoughts of circumcision until seen by a urologist. This is because the foreskin can provide essential additional skin needed to reconstruct the urethra.
We often repair hypospadias before a child is one year of age. This way, the boy is in diapers and management of dressings are made easier. However, the exact age of repair can vary according to the size of the penis and severity of the defect. We have been able to repair most of the children with a single operation, but on occasion, a second operation may be needed. The operation is performed under general anesthesia with the child completely asleep. Most of the boys will have a small tube exiting the tip of their new meatus. This "stent" will protect the new urethra and allow for adequate healing. Most patients leave the hospital the same day or the following day. However, more complex repairs for the more severe types of hypospadias can require longer hospital stays due to the need for bedrest and immobilization in the immediate post-operative setting.
The exact type of operation employed varies according to the severity of the defect. For the more distal defects that have openings closer to the normal position at the end of the penis, a new tube can be created from the surrounding skin. This creation of a tube is known as a Thiersch-Duplay repair. For more severe defects, the options range. Additional hairless skin is often needed to recreate the urethral tube when longer defects are seen. Here, the subdermal skin of the foreskin can be used. For the most severe defects, we can remove mucosal skin from the inside of the cheek or use subdermal skin from other hairless parts of the body. It is important to use hairless skin as future hair growth in the neourethra can present multiple problems.
The usual risks of surgery are present when we perform hypospadias repairs. Risk of infection is controlled with use of antibiotics with the surgery and in the post-operative setting. Bleeding is well controlled by using a penile tourniquet during the operation. This limits the blood loss to a very minimal amount, while allowing for good visualization of the tissues for the surgeon.
By using good surgical technique we are able to minimize the longer-term complications of the surgery. The most common problems that present are fistula and stricture. A fistula occurs if a hole develops along the pathway of the repair proximal to the tip of the penis. In other words, a hole can develop along the underside of the penis allowing for leakage of urine. Additionally, a stricture is a scar that can form causing a narrowing in the urethra. If either of these complications occur, an additional repair will be needed usually 6 months later.
Below, we have included our typical post-operative instructions for parents after their son has undergone surgery at our center.
Discharge Instructions for Patients After Hypospadias Repair
Once your son is at home, he does not have to stay in bed, but he needs to be watched closely. He may walk and play QUIETLY. Your son may not use straddle toys, walkers, or bicycles until it is okayed by his doctor. His doctor will also tell you when he can return to daycare or school.
For the first day after surgery, your son may have fruit juice, soups and crackers to help prevent stomach upset. It is important that your son drinks plenty of fluids. Give him foods high in fiber, such as cereal or fruit to prevent constipation.
Children recovering from hypospadias repair usually experience some soreness. Your son's doctor will prescribe medication to help relieve the pain. Give your son the pain medication on a regular schedule, as prescribed by his doctor, to keep him comfortable.
In addition to pain medication, your son's doctor may prescribe anticholinergics to help decrease bladder spasms. Bacitracin is an antibiotic ointment used to help prevent infection and soothe the penile area. You can buy bacitracin in any drug store without a prescription.
Your son will go home with a clean bandage or dressing around his penis. Leave the bandage in place. You do not need to change it. Keep the bandage as dry as possible and change your son's diaper often. After bowel movements, wash your son's bottom with warm water and gently pat dry. Do not use diaper wipes that have alcohol because they can sting. If your son's penis or bandage gets soiled with stool, rinse him gently with a mixture of hydrogen peroxide and water. You can buy hydrogen peroxide in any drug store without a prescription.
Your son's penis will look red and swollen for a while. Applying bacitracin ointment gently on the tip of his penis 4 to 6 times a day will soothe the area and help prevent infection and crusting. The bandage may fall off by itself. If it does, apply bacitracin on the entire area until it is completely healed.
Give your son a sponge bath for the first 7 days. As long as your son does not have a tube or stent, he may take a bath in the bathtub after 7 days. It is okay if the bandage falls off in the tub. Use only warm water for the first bath (NO SOAP). Use double diapers to protect and pad your son's penis for one week. Dress your son in loose fitting clothing such as sweat pants or loose pajamas to keep him comfortable.
Care of Stent
A stent is a small, soft tube that is placed in the urethra and sometimes the bladder to hold it open during healing. A stent will be inserted in the urethra and a dressing will be placed around the penis. The stent will be sutured in place during surgery; its tip visible at all times. It is acceptable for your son to urinate around as well as through the stent. The stent will be removed during your son's post-operative visit. Care of the bandage is the same with or without a stent. When you put bacitracin on the penis, be careful not to block the stent. Although the suture holding the stent in place will keep it attached to the penis, the pressure of the urinary stream may cause the stent to fall out (do not attempt to put it back). If this happens, do not be alarmed, just notify your doctor. The stent will stay in place for 7 to 21 days after surgery. It will be taken out in the doctor's office.
Seek Immediate Attention From Your Doctor If:
- You notice bleeding from the stitches or blood in the urine (red diaper). It is okay if the urine is pink tinged for a few days.
- Fever of 102°F or higher for more than 24 hours.
- Your son has continued nausea and vomiting after the first day.
- The bandage seems too tight or the penis tip is gray or blue.
- You notice your son is straining or unable to urinate.
- You cannot see the tube or if it falls out (do not replace it).
- Your son has severe pain that doesn't get better with pain medication.