Hypospadias | AHTCS

Cleft Lip and Palate: Hypospadias Information for Parents
What is Hypospadias?

Hypospadias is a congenital deformity of the penis - in other words a deformity that is already present at the time of birth. It is a fairly common problem, affecting approximately 1 in every 200 boys. In hypospadias the urine tube (Urethra) has not grown right through to the tip of the penis. Instead it opens on the underside, somewhere further back than is normal.

What does hypospadias look like?
The appearance can vary depending on the severity. The diagram shows an average hypospadias, with the opening of the urethra (Meatus) lying just below the head of the penis (Glans). In severe cases the opening may be at the base of the penis or even right back on the scrotum. In a young baby it is not always easy to tell where the urine is coming from, as the misplaced opening is often quite small and difficult to see. Usually a hooded foreskin is the most obvious sign that the boy has hypospadias. Instead of having a circular foreskin, some of it is missing on the underside, and the remainder forms a floppy wrinkled hood over the back of the glans. In addition the penis often has some downward curvature (Chordee) when it is erect.

Why does it happen?
The exact cause is not known but the deformity occurs during the first 3 or 4 months of life in the womb, during the time when the genitals are forming. In hypospadias, the penis does not quite complete all of its development. There is a familial tendency, because in at least 20% of cases 1 or more male relatives also have hypospadias.
What if we have more children?
If you have one son with hypospadias and this has not happened before in the family, then there is probably a 1 in 10 chance that if you have another son, he will also be affected. If there is already hypospadias in the family, then the chances will be much higher - maybe as much as 1 in 3 or 4.

My child has no problems from his hypospadias, so why should he have an operation?
During early childhood the less severe forms of hypospadias usually cause no symptoms or concerns, so parents will naturally wonder whether surgery is justified for what seems like just a minor 'cosmetic' problem. We know however that when hypospadias is left untreated, the great majority of boys will develop spraying or misdirection of their urine by the time they reach their teens. The abnormal appearance may also cause social embarrassment or psycho-sexual difficulties once they realize that their penis is 'different'. Hypospadias could be operated on at any time in life, but psychologically it is better to correct the deformity in childhood, before it has started to cause concerns. We prefer to wait until the age of 3, by which time most boys are out of nappies and are mature enough to make co-operative and easily managed patients. This usually allows us to complete the surgery before they start school.

What does surgery involve?
Surgery involves straightening the penis and repositioning the meatus in its normal place on the tip of the glans. In most cases it is not possible to reconstruct a normal foreskin and so the end result will usually look circumcised. Whilst we correct some minor degrees of hypospadias in a single operation, in the majority of cases we recommend a 2-stage repair, as this usually gives the most natural results and has the least complications

Stage One
Involves straightening the curvature, and grafting some of the excess foreskin onto the underside of the penis, where it will form the foundation for the missing bit of urethra. This may require a week in hospital.

Stage Two
Is done 4 to 6 months later and again may require about a week in hospital. On this occasion the skin graft from the first operation will be formed into a tube that will open on the tip of the glans, and the remaining foreskin hood is trimmed off. If you would like more information about the nursing care and daily ward routine for the time your child will be in hospital, please ask any of the ward nursing staff who can provide a detailed fact sheet and answer any questions you may have.

Can I stay with him?
After the age of 3 most boys cope very well with their stay in hospital. A familiar face is reassuring and so we encourage and provide facilities for one parent to stay with them on the ward and to accompany them to the anaesthetic room in theatre.

Will he be in much distress?
Although the surgery sounds rather painful, in actual fact there is usually very little discomfort after the first day or two. A mild pain-killer such as Calpol is usually all that is required. With TV, videos, games and a ward playleader/teacher to ensure that there are plenty of things to keep them occupied, many of the boys actually look forward to coming back into hospital for their 2nd operation.

Will the surgery be successful?
A full general anaesthetic will be necessary for the operations). Modern anaesthetics are now very safe, and serious problems are fortunately extremely rare. To further minimize any risks, the anaesthetist may wish to postpone the surgery if your child has a significant cold, cough or chest infection at the time of admission. In that case we would arrange a new date when he is fully recovered. Hypospadias repair is skilful and delicate surgery but it is not 'major' high risk surgery. With modern treatment the great majority of repairs are successful without the need for more than the planned number of operations. However even with the best and most specialized care, unexpected problems do sometimes arise. The repair may occasionally develop a leak or a narrowing in the new tube, or there may be cosmetic imperfections. In those cases an extra operation or operations may be necessary to achieve the ideal result.

Any do's and don7s offer the surgery?
In most cases catheter drainage tubes and dressings will have already been removed by the time your child leaves hospital. You may be asked to apply a mild antiseptic cream to the operation site several times a day for the first week or two, but there is otherwise little in the way of specialized aftercare required. Obviously the healing operation site should be protected from injury if possible, and so we advise against high risk activities such as contact sports and riding bikes for up to 2 months. After that however, no restrictions are necessary.

What problems will he have when he is older?
Usually None. You can expect the penis to develop and to function perfectly well after the deformity has been corrected. As a precaution we do like to see our patients for a check up from time to time, until they have finished their development around their mid teens. Then if there are any adolescent worries or questions about the hypospadias, we can deal with these. This leaflet only aims to provide basic information about hypospadias. You may require more detail or have other questions that have not been answered here. Should you need more information then please ask the medical or nursing staff on the ward and they will be pleased to help. Your surgeon must be properly qualified to do the operation and he will advise you what can and what cannot be achieved in your case. Do take that advice. Dr. Mirza Shehab Afzal Beg is a british trained plastic surgeon possessing the highest qualification of Plastic surgery in UK i.e FRCS (Plast) which no other surgeon currently practicing in Pakistan has. He has also worked as a Consultant in Plastic Surgery in UK. On his return from UK he is based at Liaquat National Hospital and also is a honorary consultant at Aga Khan Hospital.

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