Degrees of hypospadias
Problems with hypospadias
When should the operation be done?
About the operation
Hypospadias is a defect in which urine passes from an opening sited not at the tip of the penis but from somewhere on the undersurface of the shaft. This is a common birth defect and occurs in about 1 of 250 male births.
There are different degrees of hypospadias - the minor ones are those where the opening is closer the tip, and the severe ones are those where the opening is close to the scrotum or even dividing it. The abnormality of hypospadias has three components
i. The opening is away from the tip;
ii. The penis may be curved downward (called chordee) and this is readily apparent during erection. The chordee is more prominent in the more severe varieties of hypospadias;
iii. The prepuce, or the foreskin, is always deficient on the undersurface giving the appearance of a hood when the penis is viewed sideways.
Problem with hypospadias
Hypospadias is associated with several problems. The urine stream, instead of being directed forwards is usually deflected towards the feet so that these boys commonly soil their clothes and are unable to pass urine in a standing position. This, naturally, is a serious concern when the children enter school.
A reasonably straight penis is essential for normal sexual intercourse. Although this may not be an immediate concern in the child, this is an important reason for these children to have their deformity corrected surgically.
When should the operation be done?
For the reason mentioned above, the surgical repair of hypospadias must be complete before the child starts going to school. Often, the operations are done in more than one stages. The time interval between two stages of operation is about 6 months. The first operation can be done at around 1 year of age. The pediatric surgeon, based on several considerations, ultimately takes the decision regarding the optimum time for operation.
About the operation
The operation is performed under general anesthesia and usually takes between 1 -1½ hours. Blood transfusion is never required during this operation. When the child returns to the ward, he has a pressure dressing around his penis and there is a fine tube (catheter) that is inserted into his urinary bladder that drains all the urine. This catheter and the dressing usually remain for 6-7 days following which it is removed.
Several operative techniques are used for the repair of hypospadias. In most techniques, the skin on the penis or the redundant foreskin is used to create the tube from the existing opening to the tip. It must be mentioned that when the chordee or penile curvature is released the opening slips back further and requires a much more extensive operation.
Recently, more and more surgeons are correcting hypospadias by one-stage techniques that reduce hospitalization and give better cosmetic results in the long-term. Needless to say that these techniques are more demanding.
The operation must be done by pediatric surgeons who have substantial experience in this type of reconstructive surgery. In spite of all precautions problems may be encountered in about 10-15% patients. The common problems that may occur are:
1. Bleeding: A small amount of bleeding into the dressing or in the urine tube is not uncommon. This is a transient problem.
2. Infection: This is a real risk and can damage the newly reconstructed tube leading to its breakdown. Antibiotics are therefore routinely prescribed following this operation.
3. Bladder spasms: This is the nastiest problem in the post-operative period. Due to the tube in the urinary bladder, the bladder muscle frequently goes into a spasm that is extremely painful. Unfortunately, medicines can only reduce the frequency or severity of these spasms, but can not completely eliminate them. Similarly, erection of the penis in the tight dressing also causes much discomfort that can hardly be helped.
4. Urine leakage: Sometimes due to kinking of the catheter or while straining to pass stools, few drops of urine may leak around the catheter and wet the dressing. This, again, is not a worrisome thing.
5. Urine fistula: After removing the catheter, the child may pass urine from more than one places along the stitch line. The chance of this fistula is higher with repairs for the more severe hypospadias. These fistulas are easily closed surgically, but no sooner than 6 months after the initial repair.
6. Residual chordee: A penile curvature of about 10º may be acceptable after repair of severe hypospadias. This degree leads to no functional disability.
Sometimes the new urinary opening may become tight, usually
within the first 3-4 months after surgery. This may need
dilatation (stretching) for sometime.
Dr Anurag Krishna,
MBBS (AIIMS), MS (AIIMS), MCh (AIIMS), MAMS, is a Consultant
Pediatric Surgeon at Sir Ganga Ram Hospital in New Delhi.
Formerly Associate Professor of Surgery, University College of
Medical Sciences, Dr Krishna has a special interest in pediatric
urology. He has had an active academic career, has published
several papers in national and international journals, and is the
Editor (with Dr Suneet Sood) of a widely acclaimed book titled
Surgical Diseases in Tropical Countries.
Contact Nos: Res 6884887, 4102687, Hospital: 5721800, 5781837, Fax 5751002, email firstname.lastname@example.org, www.sgrh.com