What is hypospadias?
Hypospadias is a defect in which urine passes from an opening sited not at the tip of the penis but from somewhere on the under surface 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: -
- The opening is away from the tip
- 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
- The prepuce, or the foreskin, is always deficient on the under surface
giving the appearance of a hood when the penis is viewed sideways
What are the problems 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 stage. 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 paediatric surgeon, based on several considerations, ultimately takes the decision regarding the optimum timing of operation.
How is the operation performed?
The operation is performed under general anaesthesia 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 hospitalisation and give better cosmetic results in the long-term. Needless to say that these techniques are more demanding.
What are the possible complications of the operation?
The operation must be done by paediatric 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:
- Bleeding: A small amount of bleeding into the dressing or in the urine tube is not uncommon. This is a temporary problem.
- 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.
- 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 cannot completely eliminate them.
Similarly, erection of the penis in the tight dressing also causes much
discomfort that can hardly be helped.
- Urine leakage: Sometimes due to kinking of the catheter or while straining
to pass stools, a few drops of urine may leak around the catheter and wet the
dressing. This, again, is not a worrisome thing.
- Urine fistula: After removing the catheter, the child may pass urine from
more than one place along the stitch line. The chance of fistula is higher with
repairs for the more severe hypospadias. These fistulae are easily closed
surgically, but no sooner than 6 months after the initial repair.
- Residual chordee: A penile curvature of about 10º may be acceptable after
repair of severe hypospadias. This degree leads to no functional disability.
- Stricture: Sometimes the new urinary opening may become tight, usually
within the first 3-4 months after surgery. This may need dilatation (stretching)
for some time.