Hypospadias

What is hypospadias?
Hypospadias is a deformity of the penis that is present at birth and derives its name from the Latin (hypo- meaning under, and spadias- meaning rent, hole) where the hole for the urethra is situated under the penis rather than at the tip. It is relatively common, occurring in 1 in every 400 male births. In hypospadias, the urethra (urine tube from the bladder) has not grown all the way to the tip of the penis and opens on the underside of the penis instead. Most often this is just under the glans (head) of the penis, but in severe cases can be located at or about the scrotum. Commonly with this condition, the boys are unable to attain a straight erection.

What causes hypospadias?
The exact cause for hypospadias is unknown but the deformity occurs during the first 3-4 months development in the womb. The deformity can not be prevented and is not the result of anything that either parent has done, or not done, during or before the pregnancy.

Are any other tests needed?
Not usually, as associated abnormalities are uncommon. Occasionally hernias or undescended testes are diagnosed by the surgeon at the initial assessment. In severe cases, hormone studies or imaging of the urinary tract may be recommended.

Is it hereditary?
If you have a son and a first degree relative (uncle, father) with hypospadias there is a 1 in 3-4 chance a subsequent son will have hypospadias. If your son is the first in the family to have hypospadias then his brother would have a 1 in ten chance of having hypospadias.

What can be done about hypospadias?
Most parents agree to surgical correction of the hypospadias deformity. The goals of surgery are to enable a boy to pass urine standing up, attain a straight erection and have a normal appearing penis.

Why should my child have an operation for hypospadias?
While your boy is in nappies, the hypospadias may seem little more than a cosmetic problem. However, once he is older he may have problems with spraying of urine and may have to sit down to pass urine. When your child becomes fully matured, he may have difficulty with intercourse due to the bend in his penis.

Surgery is usually offered at the age of three in order that it is well completed by the time they go to school.

What does the surgery involve?
The aim of surgery is to complete the job unfinished by nature by straightening the penis and moving the urethral opening to the tip of the penis. In most techniques this involves removing the foreskin to give a circumcised appearance. It is important that your child is not circumcised prior to hypospadias surgery as this tissue is vital to the operation.

What techniques are available?
Essentially, only two techniques are used now to correct this deformity.

Snodgrass. This is named after a Paediatric Urologist in Texas who publicised his technique in the early 1990s and has now become industry-standard for most hypospadias cases. This a single-stage operation which provides a very normal looking result with a low complication rate.

Two-Stage (Bracka) Repair. This is named after a Plastic Surgeon who worked near Birmingham, UK. This can be used for more severe cases and also revision/salvage work which is sometimes required. Stage one surgery involves placing a graft into the head of the penis. The second stage is undertaken six months or more later when the graft has matured at which time it is tubularised around a temporary catheter to create a new urethra.

Each operation requires 5-7 days in hospital (usually with a parent staying).

What complications can occur?
All surgery runs a risk of developing complications despite the best and most specialised care. Very occasionally, boys need to return to theatre as a result of bleeding following surgery. Theoretically, infection is a possibility although I have never seen this. Graft loss is exceedingly uncommon however shrinkage of grafts may occur and require a "Stage One-and-a-half "operation to insert more graft before definitive closure is possible. Narrowing (stenosis) and leaks (fistulae) are uncommon problems that can usually be solved with a further minor procedure. Sometimes , cosmetic imperfections such as a twisted penis (torsion) or asymmetric/irregular foreskin need "touch-up" procedures. Thankfully, the newer techniques used now are much less prone to failure as those used previously.

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