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Brian A. Roelof, M.D. HYPOSPADIAS is a common birth defect found in boys in which the urinary tract opening (urethral meatus) is not at the tip of the penis. Instead it is found on the underside of the penis somewhere between the tip of the penis and the area behind the scrotum. Hypospadias occurs in approximately one out of 200 male births. Often, there is an associated downward bending of the penis when the penis is erect. This condition is called chordee. There are varying degrees of hypospadias. Some are quite minor and others are much more severe. The degree of hypospadias is classified by the location of the urinary opening. It must also be determined if chordee is present and, if so, is it mild, moderate, or severe in nature. The foreskin (prepuce) is always present in a "hooded" form rather than wrapping all the way around the head of the penis. Heredity If a boy has hypospadias, there is a 10 - 20% chance that another member of his family, such as a brother or father, will also have hypospadias. If you have a subsequent male child, he would have a 10 - 20% chance of having hypospadias. A person with hypospadias has a 10% chance his male children will also have hypospadias. Embryology The penis begins to form very early in fetal life. Urethral folds unite in the midline to form a urethral groove that becomes the urinary tube (urethra). A small dimple forms at the tip of the penis and grows inward to meet the urethral tube that is extending from the bladder. With a hypospadias problem, the tube coming from the bladder does not reach the short tube coming from the tip of the penis and thus the opening is not at the tip. The foreskin (prepuce) also does not form properly as noted above. There is a higher risk of hypospadias in premature infants. Reasons for Repair Most boys and men prefer to be able to stand and point their urinary stream directly at the toilet. If the urinary stream comes from the underside of the penis, the child may have poor directional control, and thus may need to sit on the toilet to direct his stream into the toilet. This puts them at a social disadvantage. Surgical correction of hypospadias involves a straightening of the bending (chordee) and the extension of the urinary tube (urethra) towards the tip of the penis. This is done under a general anesthetic. Often at the end of the procedure, a long-lasting local anesthetic is used to minimize the pain in the first few hours after the operation. A straight penis is necessary for satisfactory sexual function later in life. This is why it is important to correct the bending (chordee) of the penis. If the problem is moderately severe, he may not be able to cause a pregnancy because the semen does not come out from the tip. Possible Problems Related to Surgery Bleeding is a risk of any operation. During the procedure, we make a great effort to carefully control the bleeding. Careful surgical technique is used including the use of catheterization and Epinephrine. Often a pressure dressing is used to reduce the chance of bleeding after the procedure. A transfusion for hypospadias repair is extremely unusual. Infection is always a concern. Antibiotics are used during and after many of the repairs to reduce the chance of infection. Catheter problems: When a catheter is used to drain the urine, it may sometimes cause painful BLADDER SPASMS. There may be leakage of urine around the catheter during the spasm. Other catheter problems include kinking which may cause urine to leak around the catheter rather then through it. The catheter may also become plugged. Fistula is a recognized risk of hypospadias. This is the leakage of urine somewhere along the newly formed urethra. There is minimal risk in the simple repairs, but the risk goes up significantly for the more complex operations. If fistulas occur, they are usually fixed by an outpatient surgical procedure six months or longer after the original operation. Some of the fistula repairs may require more than one surgical procedure. Scarring can result from many causes. Other complications include a narrowing (stricture) where the new urethra joins the original urethra or a narrowing at the tip of the penis. Sometimes there continues to be persistent bending (chordee) that will require further correction. We attempt now to repair virtually all the hypospadias problems with one operation. In the past, instead of attempting a one-stage repair, we would have scheduled the child for multiple procedures. It must be recognized that many of the children will need further surgical correction to remove skin tags or repair fistulas or to correct strictures, etc., even though we originally attempted a "one-stage" repair. Almost all hypospadias operations are done as an outpatient procedure, that is, your son will go home on the same day the surgery is performed. This seems to be very safe. Chordee Without Hypospadias This is a less common problem in which the urethra extends to the tip of the glans penis, but there is a bending of the penis when the patient has erections. This is usually corrected so that the child may have normal sexual function later in life. Circumcision We always recommend that the infant NOT be circumcised at birth. We need the foreskin to be available to us if we need it to replace the short skin on the underside of the penis. The prepuce is special skin as it is thin and hairless. Also, it may be used to create the new urinary tube. At the time of the hypospadias repair, prepuce (foreskin) will be used in the course of the operation or will be removed so that the child will appear circumcised at the end of the procedure. Intact Prepuce Megameatus Variant This is an uncommon form of hypospadias. The prepuce appears normal, (not hooded), and the boys are usually circumcised before it is recognized that their meatus (opening) is very large (mega) and may extend down onto the shaft. It is not the fault of the circumcision. Age of Operation The repair is usually done between 6 and 12 months of age. The baby can tolerate the anesthetic well, will heal rapidly, will not remember the operation and the baby sitters usually have not figured out there is a problem. In the past they were corrected at an older age. Operations The following are samples of some of the more common operations. The field of hypospadias repair is constantly changing with new techniques, new catheters, new dressings, and new philosophies. It is really quite a complex surgery to be able to straighten a penis, place the urinary opening at or near the tip, not have urethra fistulas, and to have good cosmetic results, etc. |
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