Mild hypospadias

What is hypospadias?

This is a condition where the urethra (hole where urine comes out) is not in the correct place. It is instead further down and on the underside of the penis. The type of hypospadias is described by where the opening is. The mildest type (glanular) is where the opening is on the head of the penis.

Openings further back (on the penis itself or at the base of the penis) are uncommon. In addition to the hole being in the wrong place, the foreskin is often not formed properly. This leads to the foreskin looking ‘hooded’.

Sometimes the penis is bent downwards, usually because of tight skin but sometimes because of abnormality of the body of the penis but these are rare with mild hypospadias.

Is this common?

Yes it is common. It happens to around between 0.3 percent to 0.4 percent of children. Of these, 80 percent are the mild types of hypospadias.

Is it associated with any other abnormalities?

Mild forms are rarely associated with other abnormalities so no other tests need to be done.

Why does it happen?

The urethra (hole where urine comes out) forms from a strip of special skin forming itself into a tube on the under side of the penis. It closes up like a zip fastener pulling closed from the back end to the tip of the penis. For some reason the end part of the tube fails to form and remains as a flat plate. The underlying cause is unknown in most cases.

There are several theories why this happens including an increased female hormone-like substances in the environment causing mild forms of hypospadias. Very occasionally it seems to run in families.

Is surgery needed?

Surgery may be needed for 2 reasons:

1. To make everything work properly (make the pee comes out straight and to make the penis straight)
2. For cosmetic reasons

If your child can pass urine forwards then the operation is purely cosmetic and as such does not have to be done. We would prefer to do surgery if and when the young person wants it themselves. That being said, there is a risk of your child becoming upset by the appearance as they gets older and the surgery is less sore and heals better if we do it when he is young. There is a risk if is mild and you have a complication you might regret having made the decision to go ahead. We are here to help guide you through this decision making.

When is surgery done?

Technically surgery can be done at any age. We prefer to operate around 9 to 18 months for a few reasons:

• the operation is less upsetting at this age
• they are not potty trained and cannot control their pee (older children may refuse to pee after such operations causing trouble)
• the penis is a reasonable size on which to operate

What does surgery involve?

There are a few operations that can be used. The goal of all the operations is to bring the opening to its correct position in the tip, correct any bend and reform the foreskin.

If you wish the foreskin can be removed (circumcision) instead of being reformed.

How long does the operation take?

The operation takes between about half an hour to 3 quarters of an hour. Anaesthesia is needed for this operation, so we need some time to let your child wake up afterwards. This can take quite some time and depends on the the individual.

For mild (glanular) forms of hypospadias, the operations are done as day cases. This means your child will be in and out of hospital in a day.

What complications can occur with surgery?

Children at the age of 9 to 18 months usually get over surgery very quickly and easily. Hypospadias operations are not particularly uncomfortable although weeing for the first few days may be a bit difficult.

There can be some bleeding into the dressing or the wound may get a mild infection.

The penis always swells and bruises. Sometimes this can look quite worrying, but as long as your child is weeing easily there should be no reason to worry. Bruising may take a couple of weeks to go down (especially with the larger operations) and the swelling should go down after a few months.

In about 5 percent of surgeries, there can be a partial or complete breakdown. This is where the hole is on the head of the penis will be followed by the hole opening not quite as far up the glans as it should. The worst that can happen is that the opening goes back to where it was before the operation. Even if this happens the stream of urine is usually straighter than it was.

Sometimes the new opening of the urethra becomes narrow (a stricture) which may be treated by stretching or by a further adjustment operation.

When the foreskin is reconstructed to make it complete, the operation is done to deliberately leave the foreskin ‘loose’. This is to stop the foreskin being too tight and causing problems later. The foreskin repair can break down leaving the foreskin looking hooded again. This happens in around 10 percent of operations. The foreskin can then be left, removed or reconstructed again later.

What will it look like after the operation?

Sometimes the penis will have no dressing at the end of the operation. Instead, either a gauze dressing is used which is then taken off about 2 to 3 hours before going home, or clear dressings are used which can be soaked off in the bath after a couple of days.

There may be a little spotting of blood from the wound or moistness that dries within a day. The foreskin may become bruised looking and it may swell a lot and look worrying. This does not mean it is not going to heal and although it looks painful, it is generally not. The swelling and bruising goes down in about 2 weeks, although it may take a few months before the skin looks normal.

Several types of dressing are used, your surgeon will inform you before the surgery about this.

When can I bath my child after surgery?

While any dressing is in place you should not bath your child. Wounds take 48 hours to seal and a another 7 days to become strong.

If the dressing is removed on the day of operation there is no worry of letting the wound get wet but should not be wet for a long time. Bathe your child as quickly as you can for the first 3 days to make sure the wound is not wet for longer than it needs to be.

If the dressing is taken off after 1 or 2 days it is a good idea to bath carefully but only for a brief time.