Hypospadias is a congenital abnormality in which the opening of the male urethra is located near the glans penis or along the shaft of the penis or in extreme cases the urethra is located at the base of the penis or under the scrotum. It can be diagnosed at birth. It is absolutely necessary for a child to undergo surgery in order to lead a normal life. Hypospadias is usually surgically corrected within twelve months to three years after the child has been born, depending on the severity of the condition. Often males with hypospadias have chordee, a condition in which the penis bends downward during an erection.
Uncorrected hypospadias puts a child at risk for urinary tract infections. The child may also have malformed foreskin. If the condition is left untreated a child might have difficulty toilet training, social interaction with other boys and problems with sexual relations in adulthood. Surgical correction hypospadias is controversial because it is genital surgery. Some people regard it as an unnecessary interference with a child’s body and a traumatic experience with psychological consequences extending into adult life.
Causes of hyposadias are not yet fully understood, the condition is thought to be the result of a combination of factors. Genetic disorders, low birth weight, environmental contamination have been associated with an increased risk of hypospadias. Statistically it affects up to 4 in 1,000 boys and the number of boys born with hypospadias has increased since the 1970s. Caucasians have the highest rates of hypospadias and is more common in males of Jewish or Italian descent. Hispanics have the lowest and African Americans have medial rates.
Surgical repair is done for many reasons both physical and psychological. The abnormal location of the urethra opening forces many boys to sit down while urinating, which leads to anxiety about using public restrooms and being seen naked by their male peers. Correcting chordee would allow the child to have normal sexual intercourse as an adult. It is common in hypospadias for the urethra to be narrowed, or stenotic. A stenotic urethra increases risks of frequent urinary tract infections. Also, Hypospadias has been identified as a risk factor for developing testicular cancer later in life.
Surgery can help confirm the boy’s sexual identity by improving the outward appearance of the penis. The severity of hypospadias is defined according to the distance of the urethral from its normal location at the tip of the penis. In mild hypospadias the urethral opening is located on the shaft of the penis just below the glans penis. In mild to moderate hypospadias, the opening is located further down the shaft of the penis toward the scrotum. In severe hyposadias, the urethral opening is located on the scrotum. About 80-85% of hypospadias are classified as mild.
10-15% as mild to moderate. 3-6% as severe. Surgeons disagree regarding the best age for hypospadias repair in boys. Most surgeons think the surgery should be done between 12 and 18 months of age because it’s prior to toilet training age and the child is less likely to remember the operation. Some doctors prefer to wait until the child is three years old, especially if the repair involves extensive reconstruction of the urethra. The specific surgical procedure to correct the condition depends on the severity of the hypospadias.
Infants with hypospadias are not circumcised because the foreskin may be needed for tissue grafting during repair. The objectives of surgery always include widening the urethral opening, correcting chordee if present, reconstructing the missing part of the urethra and making the penis look as normal as possible. Most surgeries take between 1- 3 hours and are performed under general anesthesia. Mild hypospadias can be corrected in a one step procedure known as a meatal advancement and glanduloplasty, or MAGPI.
In a MAGPI procedure, the opening of the urethra is moved forward and the head of the penis is reshaped. More severe hypospadias can be corrected in one operation, which involves separating the skin from the shaft in order to cut the tissue that causes chordee, and forming a new urethra that will reach the tip of the penis. The specific method of reconstruction is usually determined in the operating room, when the surgeon or surgeons can determine how much tissue will be needed to form the new urethra. In some cases, tissue must be taken from the inner arm or lining of the mouth.
Recent advances in hypospadias repair include the use of tissue glues and other new surgical adhesives that speed healing and reduce the risk of fistula formation. Various synthetic materials are being tested in constructing artificial urethras, which would reduce complications related to skin grafting. Some surgeons prescribe small doses of male hormones to be given to the child in advance to increase the size of the penis and improve blood supply to the area. The child may also be given a mild sedative immediately before surgery to reduce memories of the procedure.
Many anesthesiologists provide a penile nerve block to minimize the child’s postoperative discomfort. Dressings are left in place for about four days. The surgeon places a stent, which is a short plastic tube, held in place with temporary stitches or a catheter to keep the urethra open. The child is usually given antibiotics to reduce the risk of infection until the dressings, stent or catheter is removed, usually 10-14 days after surgery. Annual follow-up tests of adequate urinary flow are scheduled for three weeks, three months and twelve months after surgery.
Regarding long-term aftercare boys who have had any type of hypospadias repair are routinely scheduled for follow-up visits through adolescence to exclude the possibility of chronic inflammation or scarring of the urethra. In some cases, psychological counseling may be necessary. Risks and complications such as bleeding and infection are a possibility, like that of any operation performed. There are some risks specific to post hypospadias operation such as wound dehiscence, which is a reopening of the incision. Dehiscence is treated by a follow-up operation.
Bladder spasms can be caused by the urinary catheter, and are treated by medications to relax the bladder muscles. Fistula formation, an opening that forms between the reconstructed urethra and skin can occur but most that form post surgery close by themselves within a few months, others have to be closed surgically. Complications from recurrent chordee require additional operations. Urethral stenosis can be present after surgery and is treated by widening the urethra using urethral probes. In almost all cases of hypospadias repair the success rate is high.
The affected children are able to urinate as their male peers do and are able to have normal sexual intercourse as adults and almost all are able to have children. In conclusion, surgery to correct hypospadias early in the child’s life is absolutely necessary for the child’s overall mental and physical health. If I had a son with hypospadias I would look to surgery to fix his malformed urethra. Although it would be painful his best interest would be in place. He would be able to interact with other boys with out fear that he does not “fit-in” and as an adult he will be able to have normal sexual relations.