Moderate hypospadias

What is hypospadias?

This is a condition where the urethra (hole where pee 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.

Moderate hypospadias is where the urethra is where head of the penis meets the body of the penis (coronal and sub-coronal). Openings farther back (on the penis itself or at the base of the penis) are uncommon, and are considered severe.

In addition to the hole being in the wrong place, the foreskin is often incompletely formed on the under-surface. This leads to the foreskin looking ‘hooded’. Sometimes the penis is bent downwards (chordee) usually because of tight skin but can sometimes be because of an abnormality of the body of the penis. Chordee is more common with severe 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 to moderate types (back as far as subcoronal) of hypospadias.

Is it associated with any other abnormalities?

Moderate 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.

What are the symptoms?

Usually the penis or foreskin may not look ‘right’. The urine stream may be angled downwards, and the penis may not stand out straight when erect.

How is it diagnosed?

Hypospadias is usually easy to diagnose when examined by a specialist.

Is surgery needed?

Surgery may be needed for 2 reasons:

1. To make everything work properly (make the wee 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. If it is not there is a risk of your child becoming upset by the appearance as they gets older. However this is very much up to the individual family and such surgery could be done later in life.

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 wee (older children may refuse to wee after such operations causing trouble).
• the penis is a reasonable size on which to operate.

What happens before the operation?

No special preparation is needed. It will be sore after the operation so it is a good idea to have paracetamol and ibuprofen at home.

What does surgery involve?

There are many types of operations designed to repair hypospadias.

The operations we use try to bring the hole up to the correct position on the ‘head’ of the penis (glans), make sure that the penis is straight and repair or remove the foreskin all in one operation. Many moderate hypospadias repair operations can be done as day care procedures (in and out of hospital the same day). Sometimes children may need to stay in hospital overnight and have a tube (stent) draining the urine for a few days. Our doctor will explain the type of surgery planned for your child.

What is a stent?

The surgeon may decide to leave a tube (stent) into the bladder to drain the urine. This is left in place for 1 to 7 days depending on the operation. It usually drains urine into the nappy. A bag will be attached for older children who no longer use nappies. If a stent is used for more than 2 days, then antibiotics are prescribed to stop an infection in the urine.

The tube is used to stop urine running over the internal stitches so that in the first 24 hours there is not so much stinging. When it is removed your child may still find passing urine sore but this gets better over 24 hours.

For bigger operations a catheter is used to keep urine from coming through the stitches for a longer period to help healing. This catheter may irritate the bladder causing spasms in about 10 percent of cases. If this happens it is easily treated by giving a medicine to stop the spasm.

How long does the operation take?

The operation takes between about 1 hour to an hour and a half. 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.

What are the risks with surgery?

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.

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

In operations for moderate hypospadias, the most common thing to go wrong is the new tube may spring a leak called a fistula. This happens from around 5 to 10 percent of cases. If this happens it is usually quite easy to put a few stitches in the hole at a second small operation 6 to 8 months later.

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.

About 5 percent of the time, the hole will not open 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 and the operation needs to be repeated. The whole repair failing and going back to what it was in the beginning happens around 0.5 percent to 0.6 percent of cases.

What happens after the operation?

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.

Food and drink are usually allowed as soon as your child has woken up.

The area will be sore for a couple of days but these can be helped with paracetamol or ibuprofen are useful.

For most children there will be a dressing that stays on for 1 to 7 days. This may be a gauze pad holding the penis onto the tummy wall to keep it still, or a see-through sterile waterproof dressing with antibiotic ointment on the penis to stop the dressing from sticking to the operation site. With any operation on the penis the delicate skin can become swollen and very bruised looking. This does not mean the operation is not going to be successful. This swelling sometimes happens several days after the operation, even after the dressing is removed.

When can I bathe my child after surgery?

You should not bath your child for 48 hours. It is okay to wipe the area if needed. Wounds take 48 hours to seal and a another 7 days to become strong. 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. If a dressing is to stay in place for more than 2 days a very shallow bath is okay as long as the dressing is kept above the water line. For all of these operations it does not matter if the area gets wet, as it may get wet from urine, but it must not be allowed to be soaking.

Are there any long term effects after operation?

Once the area is healed it is rare for there to be long term effects. If the foreskin has been reformed, this sometimes does not stretch and needed further treatment later. Sometimes the urethra may be a bit small and have problems weeing.

Will we need to be seen after the operation?

Your child will be seen a few weeks after the operation to make sure that the repair is healing satisfactorily. We will then keep an eye on your child at least until they are potty trained so that we can measure how fast they wee and to make sure that the tube is a good size.