Index
Most boys are born with a penis that looks normal and works well.
But some children are born with a common condition called hypospadias.
Hypospadias form a penis that not only does not work well but does not appear normal.
Pediatric urologists have devised many surgical techniques to solve this problem. The following information will help you talk with your child’s urologist.
How does the penis normally work?
The main functions of the penis are to carry urine and sperm out of the body. The urethra is the tube that carries urine and sperm through the penis to the outside.
The outward opening is called the “meatus.” Both tasks are easier when the meatus is at the tip of the head (“glans”) of the penis.
Hypospadias is a condition where the meatus is not at the tip of the penis. Instead, the hole can be anywhere along the bottom of the penis.
The meatus (hole) is most often found near the end of the penis (“distal” position).
But it can also be found from the middle of the shaft of the penis to the base of the penis, or even within the scrotum (“proximal” positions). More than 80% of children with this health problem have distal hypospadias.
In 15% of those cases, the penis also curves slightly downward, a condition called “accordion.” When the meatus opens lower down the axis, curvature occurs in more than 50% of patients.
Hypospadias is a common birth defect found in up to 1 in 200 children.
In most cases, hypospadias are the only developmental problem in these babies and do not imply that there are other failures in the urinary system or other organs.
Types of hypospadias
The type of hypospadias a child has depends on the location of the opening of the urethra:
- Subcoronal – The opening of the urethra is located somewhere near the head of the penis.
- Middle axis: the opening of the urethra is located along the axis of the penis.
- Penoscrotal – The opening of the urethra is where the penis and scrotum meet.
It is estimated that approximately 5 out of 1,000 children born in the United States each year have hypospadias, 12 making it one of the most common birth defects.
Causes of hypospadias
The key steps to form the penis take place between weeks 9 and 12 of pregnancy. During this time, male hormones tell the body to form the urethra and foreskin.
Hypospadias can be caused by problems with hormones.
Signs and symptoms
The first symptom of hypospadias is that your son’s urethra is at the bottom of his penis, as opposed to the tip.
Other signs you might see in your child include:
- A downward urinary spray (in older children with more severe hypospadias, this may mean they have to sit up to urinate).
- A downward curve of the penis, called a “chordee.”
- A “hooded” appearance to the penis, caused by an additional foreskin on top.
- An abnormal appearance of the tip of the penis (the glans).
In some cases, boys born with hypospadias may also have undescended testicles and / or inguinal hernias (that is, hernias of the groin).
Diagnosis of hypospadias
Hypospadias are most often noticed at birth. Not only is the meatus in the wrong place, but the foreskin is often not fully formed at the bottom.
This results in a “dorsal hood” that exposes the tip of the penis. It is often the way the foreskin looks that draws attention to the problem.
Still, some newborns have an abnormal foreskin with the meatus in the normal place. And in others a full foreskin can hide an abnormal meatus.
About 8 in 100 of boys with hypospadias also have a testicle that has not completely fallen into the scrotum.
Treatment
Hypospadias is fixed with surgery. Surgeons have been correcting hypospadias since the late 1800s. More than 200 types of operations have been described.
But since the modern era of hypospadias reconstruction began in the 1980s, pediatric urologists have only used a few techniques.
The goal of any type of hypospadias surgery is to make a normal, straight penis with a urinary canal that ends at or near the tip.
The operation mainly involves 4 steps:
- Straighten the shaft.
- Making the urinary canal.
- Positioning the meatus on the head of the penis.
- Circumcise or rebuild the foreskin.
Hypospadias repair is often performed in a 90-minute (for distal) to 3-hour (for proximal) surgery on the same day. In some cases the repair is done in stages.
These are often proximal cases with severe chordee. The pediatric urologist often wants to straighten the penis before doing the urinary canal.
Surgeons prefer to perform hypospadias surgery on term and otherwise healthy children between the ages of 6 and 12 months. But hypospadias can be fixed in children of any age and even adults.
If your penis is small, your doctor may suggest testosterone (male hormone) treatment before surgery.
A successful repair should last a lifetime. It can also be adjusted as the penis grows at puberty.
After treatment
Modern hypospadias surgery produces a penis that works well and looks normal (or almost normal). Many surgeons leave a small tube (“catheter”) in the penis for a few days after surgery to prevent urine from touching the new repair.
The catheter drains into the diaper. Antibiotics are often given while the catheter is in place.
Younger children seem to have less discomfort after the repair. When surgery is done between 6 and 12 months of age, as recommended by most pediatric urologists, the child does not even remember it.
Older children handle this surgery well, too, especially with the kinds of medications we now have to treat pain. In some cases, medication may be needed to treat bladder spasms.
Complications of hypospadias
The complication rate in children with distal hypospadias repair is less than 1 in 10. Problems occur more often after proximal correction.
The most common problem after surgery is a hole (“fistula”) that forms elsewhere on the penis. This is from a new path that forms from the urethra to the skin. Scars can also form in the canal or at the urethral opening.
These scars can interfere with the passage of urine. If your child complains of urine leaking through a second hole or slow urinary flow after hypospadias repair, you should see your pediatric urologist.
Most complications appear in the first few months after surgery. But fistulas or blocks may not be found for many years.
Most problems are easily resolved with surgery after the tissues have healed from the first operation (often at least 6 months).
It is not easy to think of more surgery in these unusual cases. But there are options that offer hope for success.
Unhealthy scar tissue from previous operations can be removed and replaced with new tissue from another part of the body (most often from inside the cheek).
This can create a working urinary canal and still appear normal. If your pediatric urologist has not used these techniques, he / she will direct you to a center where they are used.
Checkups after surgery
Many pediatric urologists believe that routine office check-ups are not necessary after the first few months because the risk of past problems is very low.
Others think that children should be seen throughout childhood until after puberty. You and your child’s healthcare provider will decide what is best.
Frequently asked questions about hypospadias
Does hypospadias pass through genes?
In about 7 out of 100 children with hypospadias, the father had it too. The chance of a second child being born with hypospadias is about 12 out of 100.
If both the father and the brother have hypospadias, the risk in a second child increases to 21 out of 100.
Do distal hypospadias need to be fixed?
Many parents ask if surgery is necessary for mild forms of hypospadias.
It is difficult to predict the problems that a baby will have later in life. But there are many reasons to recommend correction, no matter how severe the condition is.
Up to 15 out of 100 boys with hypospadias will have a penis that will curve downward. When the curve is severe, when the child is an adult, it can interfere with obtaining an effective erection.
While the meatus may be in an almost normal location, it is often deformed. Some holes are larger while others are too small. Many have a web of skin beyond the opening.
These abnormalities can affect the flow of urine. Some children will notice that the urine is sprayed sideways or downward. Many find that they need to sit down to void.
Bypassing can cause discomfort and irritate nearby tissues. The penis works, but these problems can be embarrassing.
A partially formed foreskin that is not fixed will always appear abnormal. This can draw attention to the problem. Studies of children with uncorrected hypospadias suggest lower self-esteem.
Most pediatric urologists today suggest correcting all the less important forms of hypospadias. In most cases, the benefits of the correction far outweigh its risks.
What type of anesthesia is used? Is it safe to sleep babies?
Hypospadias repair is performed while the patient is asleep, under general anesthesia.
Many anesthesiologists or surgeons also use nerve blocks near the penis or in the back to reduce discomfort when the child wakes up after surgery.
These forms of anesthesia are very safe, especially when administered by anesthesiologists who specialize in the care of children.
Today, it is considered safe to perform surgeries such as hypospadias repair in otherwise healthy babies.
What repair is best for my child?
The method your child’s urologist chooses will depend on several factors. These include the degree of hypospadias and how much the penis curves.
The surgeon will not know the whole situation until the operation is in progress. Surgeons performing hypospadias repairs must be familiar with many techniques.
Sometimes even mild distal hypospadias can result in a more complex repair. Most hypospadias repairs are performed by pediatric urologists with special training and skills.
How do I care for my child’s wound after surgery?
Hypospadias repair wounds do not require special care to heal properly. The surgeon can choose from many age band types or not wear any.
The surgeon will give you instructions on wound care and bathing.
If your child has a catheter, it can be allowed to drain into diapers. Diapers can be changed as usual. If your child is older, the catheter may be attached to a bag.
Your healthcare provider will teach you how to empty the bag. Catheters are often kept in place for 5 days to 2 weeks.
How long will healing take?
Wound healing from hypospadias repair begins immediately. But it can take many months for it to heal completely.
There may be swelling and bruising early on. This improves in a few weeks. Sometimes the skin of the penis heals with what appears to be an unsightly frill.
There may also be more obvious complications. Any recommendation for further surgery will not be made for at least 6 months, to allow the tissues to heal.
Many minor blemishes will also resolve during this time.
If my son still has problems after many operations, can his hypospadias continue to be repaired?
Yes. Fortunately, most operations are successful the first time. However, some children need more surgery due to complications.
Most of them will have good results the second time around. However, some may have problems that lead to more surgery. But these problems can be fixed.
