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What is hypospadias and what causes it?

Hypospadias is present in 1 in 250 boys from birth and it affects their penis.

It has up to 3 characteristics:

1. The hole that urine passes through is not in the correct place.
2. The foreskin is absent at the front of the penis, with excess at the back.
3. The penis may be bent when stiff (chordee).

Hypospadias can vary in severity. For example the urine hole maybe only a small distance from the tip of the penis, whereas in others it may be at the base of the scrotum.

We do not know what causes hypospadias but there is lots of research trying to find this out, but it is unlikely to be anything that has happened during pregnancy. Hypospadias can be associated with other conditions such as hernias and undescended testes.

Most children are diagnosed at routine baby checks and are referred to a paediatric urologist who will assess the severity and plan treatment.

What happens in the operation?

Hypospadias is not life threatening. It can however mean that as your child gets older he might not be able to pee standing and having an adequate erection and sex might be difficult.

There is no alternative to an operation for treatment of hypospadias, although in some of the milder forms parents / guardians may decide to wait until their child can be part of the decision making process.

Are there any alternatives to an operation?

The operation is carried out under a general anaesthetic and lasts between 1 – 3 hours, depending on the severity of the hypospadias. The aim of the operation is to create a penis that appears more normal. To do this the surgeon will:

• Straighten the penis.
• Move the urine hole to the tip of the penis.
• Remove the excess foreskin (circumcision) or reconstruct the foreskin where possible.

Sometimes the above can be achieved in one operation, however in some cases two operations may be needed.

The surgeon uses the tissues of the penis to create a urine tube, where it is absent. If there is not enough good quality tissue, then a 2-stage procedure will be necessary. During this operation a graft of tissue, taken from the foreskin or inside of the mouth would be placed on the penis. After approximately 6 months this “new tissue” will be used to form a new tube. Sometimes other graft material is used to support the repair, but the surgeon will discuss this with you at the time.

What are the risks?

All operations have a risk of bleeding and infection. Your child will be given antibiotics to help prevent this, but occasionally this can cause the wound or graft to open. A urinary catheter or tube is placed during the initial recovery to aid your child passing urine and this can cause bladder spasms, for which you will receive medication.

In 1 in 15 boys the original hole can open again, this is called wound dehiscence OR a “fistula” and it could appear that your child is peeing through two holes. This can happen at any point after the operation and will require a further procedure.

Sometimes the new hole created at the tip of the penis can become narrowed or “stenosed” and again this would require a further, smaller procedure to widen the opening.

How do I look after my child after?

Your child will recover from the anaesthetic and they will be able to eat and drink soon afterwards. If your child is still in nappies he may come back from theatre wearing 2! This is what we call double-nappying; the inner nappy collects stool and has a hole cut out at the front.

Through this hole his penis will poke through wrapped in a dressing. There will be a plastic tube called a urinary catheter placed through the urethra (wee pipe) into the bladder. This will either be attached to a bag draining urine OR will be left to drip an outer, second nappy.

Catheters can cause bladder spasms, which cause tummy pain, or discomfort around the penis, you will be given medication, called oxybutynin for this. Regular paracetamol, ibuprofen will be required, and we advise that you have a supply of this ready at home before the procedure. We also provide a few days of oral morphine, in case other medications are ineffective. A pain medication card will be given to you on the ward with the right doses on for your child’s weight. We would anticipate you going home on the day of surgery.

Your child will be uncomfortable for a day or two. You can pick them up, cuddle them and treat them normally from immediately post operatively. The dressing and drainage tube stay in for at least a week; nursing staff will explain how to look after these before going home. Baths and showers should be avoided until after everything is removed.

Will I be followed up?

Should your child have severe pain, not improved by medication, oozing from the wound, the dressing falls off, the amount of urine draining reduces or stops or the tube falls out please contact the number below.

You will need to come back after approximately one week for dressing removal. If your child has had a single operation the dressing will be removed on the ward.

This can be uncomfortable so give your child the full pain relief in the morning before you leave home, do not give the bladder spasm medication – oxybutynin.

If your child has had the first of two operations the dressing will be removed under a further general anaesthetic for the surgeon to assess the graft.
When the dressing has been removed the penis will look red, swollen, bruised this is normal and should settle.

If however you do experience problems such as increased pain, wound becomes increasingly red, hot and swollen, oozing from wound, high temperature or problems passing urine you can either visit your local GP or get in contact with us through the main hospital switchboard.

Do bear in mind there is a limit to what staff will be able to advise on without seeing your child. If your child is unwell and you need help as an emergency, you should get them to your nearest A&E.

You will be seen in clinic in approximately 6 months from the procedure, at which time an evaluation of the flow of urine may be performed if required.