What is Hypospadias?
Hypospadias is a congenital anomaly in which the urethral opening is located below the glans penis or anywhere along the ventral surface (underside) of the penile shaft.
This is a rare disorder that usually affects males and is believed to occur during 8-20 weeks’ gestation while the urethra is developing. Although commonly found in males, a form of hypospadia can be seen in females as well, in which the genital is positioned abnormally.
Nomral Urethral opening
Abnormal Urethral opening
Causes of Hypospadias
Although the sole reason of this condition is not fully understood, there are several suggested factors. Women who were treated with hormones like progesterone during the early stage of pregnancy post a high risk of hypospadias occurrence. Another hormone-related factor is the failure of the fetal testis to produce testosterone or decreased sensitivity of the body to testosterone. This may increase not just hypospadias but other genetic problems as well. This is usually associated with the presence of chordee.
In some cases, hypospadias is inherited. Male children whose fathers have hypospadias will most likely acquire the abnormality. Also, in the case of a monozygotic twin, the condition relates to the inadequacy of Human chorionic gonadotropin (HCG) produced by a single placenta that provides to 2 fetus. There is also an increased chance for women of advanced age to give birth to a child with hypospadias as well as those who used in vitro fertilization.
- Coronal – A mild form which presents the urethra immediately below the glans
- Glanular – A mild form which presents the urethra within the glans or head of the penis
- Penile – A severe or grade 3 form of hypospadia which presents urethra on penis shaft
- Penoscrotal – A severe form which presents urethra near the scrotum
- Subcoronal – A mild form which presents the urethra just below the glans
- Perineal – A severe form which presents urethra just below the scrotum
- Distal – A mild form which presents the urethra far from the attachment of the penis
Picture 2- Types of Hypospadias
The location of the urinary meatus may vary depending on the degree of the disorder:
- Mild – Hypospadia of the glans penis accounts for 50-75% of the cases. This is characterized by urinary opening located on the underside of the penis.
- Moderate – Hypospadia in the middle portion of the penile shaft
- Severe – Hypospadia of the scrotum, the urinary opening is at the level of the scrotum, also the opening can reach up to the perineum. This degree accounts to 20-30% of the cases.
Depending on the degree, the presence of chordee which the phallus is separated from the perineum is observed. Chordee is the downward or upward curve of the head of the penis.
Surgery is the only management known to mend this rare anomaly. The recommended time frame corrective action for this abnormality is between 6-15 months of the child, while there is still a minimal effect to the emotion of the child. In the hospital setting, the repair is usually done in an out-patient basis to avoid separation of the child from their parents which may grossly affect the cooperation and mainly the emotion of the child. This is proved that late onset of treatment associates with complications.
At the onset of the repair, the foreskin may not be removed because this may aid in the repair or surgery, so children with hypospadias is not circumcised. It is mentioned that only surgery is the answer to this problem and there are several reasons why surgery should be performed. These may also be coined as the types of repair;
- Urethroplasty or reposition and correcting the placement of the urethral opening,
- rebuilding the foreskin around the urethral meatus
- orthoplasty or the repair of penile curvature
- to provide a normal looking scrotum
The assessment prior to surgery is very important to note, which include the medical check up of the child, the history of illness and previous illnesses as well as counsel the parents. It is very vital for the parents to be well-informed. The general appearance of the perineal area should be inspected and a diaper rash or of the sort should be considered and postpone the procedure until the infection disappears.
An examination before the procedure is made, which include the measurement of the penis, location of the urethral opening, shape of the glans penis, width and length of the opening, chordee and its severity, shape of the scrotum and other associated abnormalities like undescended testis.
As a rule, general anesthesia is utilized for better results. It is proven that routine penile block at the onset and at the end of the procedure improves post operative pain.
Although the surgery depends on where the surgery is going to be or the part where the repair will be done, general rules are observed. And the surgery is usually done in the out-patient basis, so it will only take a few hours to finish.
Picture 6 – Hypospadias surgery Procedure
Post operative care
Right after the surgery the child should be catheterized or if not should have a diaper on to drain off the urine. If the child is wearing a diaper, use two diapers for protection or cushioning of the affected area. Any ointment or of the sort should not be applied on the area for this may cause irritation. Antibiotics are given if the child has a catheter in to prevent infection. Nerve block is given before the end of the procedure and this usually wears off 15 to 20 minutes after. The child feels discomfort and should be given Tylenol or pain reliever whether pain is present or not.
After the procedure, although activity is not barred, quiet play for children is encouraged, so as not to strain the affected area and for better healing. Also, some children develop low appetite, although this condition disappears as time goes by, well balance diet and adequate amount of fluid is promoted throughout the healing stage.
Post surgery care
Before discharge, follow up appointments are scheduled to monitor the recovery of the child and remove necessary things like the indwelling catheter. The child is also toilet trained and the doctor may need to observe if the child can now urinate while standing, this is done if the child is old enough to do so. The urine stream is also assessed and noted to determine any discrepancy from the expected result. Follow up may vary according to the doctor, but usually it can be up to 2 years after the surgery because in this stage, possible complications may arise. Although it is in the doctor’s decision how often to go back, it is advised to minimize the check up since going back to the hospital will remind the child of the abnormality he/she has and the indifference he/she may feel about his/herself.
Immediate apprehensions after the procedure are:
- bleeding, although this is very rare, it should be controlled by compressive dressing
- local edema, this is an expected complication and does not pose any long term problem
- infection, this is also a rare case, but asepsis should be well observed so as to avoid infection
Long term apprehensions are as follows:
- fistula, this is a major concern in the long run, about 10% of the patients develop this and the severity of the hypospadia plays a major role
- stenosis of the meatus, narrowing of the urethral opening is prevented by using a stent
- urethral diverticula, this is evident while the patient is voiding, a ballooning of the urethra is observed; the redundant urethral tissue is usually excised
- urethral stricture, this a long term complication that can be repaired by incision, excision and reanastomosis of the part
With modern medicine, current prognosis of this condition is very promising. With the aid of up to date anesthetics, instruments, dressing and materials used in the repair of hypospadias, treatment has been a success. Long-term studies, although the patients who had undergone the repair of hypsopadias are not satisfied with the physical appearance of their genitals, they are contented with their sex lives compared to healthy measures.
Although, surgery at present is successful, treatment for hypospadias is still evolving. Latest study showed that hypospadias early detection during pregnancy is possible. And that appropriate action can be given to avoid this disorder. With severe hypospadias, synthetic materials are now being improved to substitute the patient’s normal urethra. These are still under investigation.