Hypospadias is a birth defect in boys in which the opening of the urethra is not located at the tip of the penis. In boys with hypospadias, the urethra forms abnormally during 8-14 weeks of pregnancy. The abnormal opening can be anywhere, from just below the end of the penis to the scrotum. Depending on the site of the opening they are classified as distal (minor type)and proximal (major type).

The types of hypospadias a boys has depends on location of the opening of the urethra:

1. Subcoronal: The opening of the urethra is located somewhere near the head of the penis.
2. Midshaft: The opening of the urethra is located along the shaft of the penis.
3. Penoscrotal: The opening of the urethra is located where the penis and scrotum meet.  

Understanding the normal penis and urethra

The normal urethra is a tube through which that urine flows out of the bladder. It passes through the penis. The opening of the urethra (meatus) is normally at the end of the penis, partly covered by the foreskin.

What is the penis like in hypospadias?

The main problem is that the urethra opens on the underside of the penis instead of at the end of the penis. The opening can be anywhere from just below the normal position (mild) to as far back as the base of the scrotum (severe).

Hypospadias may also include the following:

• A hooded appearance of the foreskin. This is because the foreskin does not develop on the underside of the penis.
• Tightening of the tissues on the underside of the penis (called ‘chordee’). This pulls the penis down and it cannot fully straighten. This is commanly seen in severe hypospedias

What problems can hypospadias cause?

Problems are likely to occur if hypospadias is left untreated. The further back the opening of the urethra is, the more severe the problems are likely to be.

• Passing urine is different to normal. A baby in nappies will have no problem. However, when older, the urine stream may not be able to be directed forward into a urinal. When going to the toilet the urine is likely to ‘spray’ backwards. Sitting on a toilet may be needed to pass urine without mess.
• Chordee causes bending of the penis. This is more noticeable when the penis is erect. Sexual intercourse may be difficult or impossible in severe cases.
• Psychological problems about being ‘different’ to normal are common.

How common is hypospadias and what causes it?

About 1 in 300 boys are born with some degree of hypospadias. It seems to be getting more common. The reason why the penis does not develop properly is still not clear. The development of the penis while the baby is growing in the womb (uterus) is partly dependent on the male sex hormones such as testosterone.

What is the treatment for hypospadias?

If the hypospadias is mild, with the opening of the urethra just a little down from normal and with no bending of the penis, no treatment may be needed. However, in most cases an operation is required to correct the hypospadias. This can usually be done in one operation. However, if the hypospadias is more complicated, two operations may be necessary. The operation is usually done when the child is around 6-18 months old. The goals of treatment are:

• For urine to be passed in a forward way.
• For the penis to be straight when erect.
• For the penis to look as normal as possible.

The position of the opening of the urethra is altered. Also, if chordee is present then this is corrected to allow the penis to straighten. The foreskin is usually used during the operation to make the new urethra so it is important that a circumcision is not done before the corrective surgery is performed.depanding on the surgery of hypospedias surgeryes

The success of the operation and the ‘normality’ that can be achieved depends on the severity of the hypospadias done in single as two stage

What happens after the operation?

Your son will be brought back to the ward to recover. He will be able to eat and drink after 3 hours He will have a dressing on his penis and a tube draining away the urine. The patients are usually kept for 2 days in the hosptial and then discharged. The dressing and tube need to stay in place for 10 days, then you will need to come back to the Hospital to have them removed.

What are the risks of hypospadias repair?

All surgery carries a small risk of bleeding during or after the operation.

For about one in ten boys, the original hole opens up again, so that your son passes urine through two holes. This can occur at any time after the operation. If this happens, your son will need the operation again. Occasionally, the new hole at the tip of the penis is too small, so your son will need another operation to make the hole larger. The drainage tube can irritate the inside of the bladder, which is painful. This is called ‘bladder spasm’. To reduce this, your son will be given ‘bladder spasm medicine’ as well as pain relief.

When you get home

Your son will go home with the catheter and dressing in place. Staff on the ward will give you full details of how to care for these at home.

• You should encourage, to drink plenty of water/fluids.
• Your child may need some pain relief when you get home.
• You should not have a bath or shower until after the dressing comes off.
• Putting your son in two nappies at a time can protect the area from accidental knocks.
• Your son should not ride a bicycle or any sit-on toy until the area has healed.
• Try to avoid getting the dressing dirty when nappy changing. If this happens, dab any faeces off with a damp cloth.
• As there is a small risk of infection, your son will need to take antibiotics until he returns for his outpatient appointment.

Post Op Teaching

• Case of cethetea
• How to empty urine bag
• How to avoid kinking, twisting, blockage of catheter or stent
• May empty straight into nappy
• How to tape drainage bag to leg allowing a child to be mobile
• Never clamp off catheter
• Child encouraged to increase fluid intake
• Twice daily sponging recommended and loose clothing
• No outdoor activity

You should contect:

• your child is in a lot of pain and pain relief does not seem to help
• there is any oozing from the wound
• the dressing falls off/becomes wet
• the tube stops or reduces the amount of urine draining from it or the tube falls out

What happens next?

You will be called for dressing as per instructions given in discharge summary. This can be painful, so before hand make sure that your son has the maximum dose of pain relief possible but no bladder spasm medicine. When the dressing has been removed, the penis will look red and swollen. This is normal and will settle down within a few days.