Dr. A.K.Singal, Author at Hypospadias Foundation

December 12 2024

Navigating Uncertainty: Understanding the Risk of Hypospadias in a Second Child

The birth of a child brings immense joy, but also concerns about their health and well-being. For parents who have experienced the challenges of hypospadias in their firstborn, questions about the risk of recurrence in a second child understandably arise. This blog aims to provide insights and guidance on this sensitive topic.

What is Hypospadias and is it necessary to repair it?

Hypospadias is a birth defect affecting boys, characterized by an abnormally positioned urethral opening. This opening, which normally lies at the tip of the penis, can be located anywhere along the shaft, scrotum, or even perineum. While the severity varies, hypospadias can affect urination, sexual function, and self-esteem. For very minor hypospadias without any chordee, family may choose to not do surgery but after consultation with an expert hypospadias surgeon. For all other hypospadias, correction surgery is recommended.

Is My Second Child at Risk of Hypospadias?

The possibility of hypospadias occurring in a second child depends on several factors:

Family history: If the father or a brother has hypospadias, the risk in subsequent sons increases. Estimates suggest 5-6% risk for a second son and this risk increases further if both father and brother are affected.
Environmental factors: Exposure to certain environmental toxins, such as pesticides and herbicides, may play a role. These pesticides are known to be endocrine disruptors, they interfere with the androgen and oestrogen signalling pathways during genital development, hence causing hypospadias. This is a hypothesis, and studies are still under process to clearly link exposure of pesticides to occurrence of hypospadias. There have been studies showing higher risk of hypospadias due to plasticisers in the single use plastic bottles. The chemicals here act as male hormone blockers and interrupt development of penis, hence causing hypospadias.
Hormonal exposure in pregnancy: During pregnancy, certain hormones may be advised for the mother to decrease the chance of preterm labour or miscarriage. This is common after invitro fertilization (IVF) conception, twin pregnancy and in precious pregnancies. Carmichael in his study reported that the use of progesterone to prevent early pregnancy loss was associated with risk of developing moderate to severe hypospadias¹.
Maternal health: Maternal smoking, pre pregnancy obesity, folic acid deficiency is some of the associated factors causing hypospadias.

Understanding the Probabilities of second child with hypospadias

While the above factors influence the risk, it’s important to understand that they do not guarantee the condition’s recurrence. Each pregnancy is unique, and predicting with certainty is impossible.

Here’s a breakdown of the estimated risks:

For a family with no history of hypospadias, the general risk is around 1 in 250 births
If the father has hypospadias, the risk rises to about 1 in 50
With a brother affected, the risk increases to approximately 1 in 30
When both father and brother are affected, the risk becomes roughly 1 in 20

Moving Forward: Taking Charge

Despite the uncertainty, proactive measures can empower parents to understand hypospadias and get proper counselling to understand the possibility of hypospadias in their second child. This includes:

Genetic counselling: Consulting a genetic counsellor can provide personalized risk assessment and guidance based on your specific family history. Genetic analysis can help us know the possibility of hypospadias in subsequent pregnancies.
Preconception care: Maintaining good health and avoiding harmful substances during pregnancy can minimize potential environmental influences. Folic acid supplementation should be started before conception and continued during the first trimester to avoid hypospadias.
Prenatal testing: While currently no specific tests diagnose hypospadias in utero, advanced ultrasound technology may detect anatomical abnormalities suggestive of the condition. This is possible only in countries where predetermination of sex of the child is allowed in ultrasound in pregnancy.
Early diagnosis and intervention: If hypospadias is diagnosed after birth, early intervention through specialized treatment can optimize outcomes. Early referral to an expert hypospadias surgeon, early surgery can help the parents and child to overcome the hypospadias problem.

Remember that Knowledge is power. By understanding the risk factors and available resources, parents can navigate the uncertainty surrounding hypospadias and make informed decisions about their second pregnancy.

Let’s work together to raise awareness and offer support to families affected by hypospadias.

Additional Resources:

Carmichael SL, Shaw GM, Laurent C, Croughan MS, Olney RS, Lammer EJ. Maternal Progestin Intake and Risk of Hypospadias. Arch Pediatr Adolesc Med.2005;159(10):957–962. doi:10.1001/archpedi.159.10.957
Urology Care Foundation: https://www.urologyhealth.org/educational-resources/hypospadias
National Institute of Child Health & Human Development: https://pubmed.ncbi.nlm.nih.gov/35398463/
Hypospadias Association: https://heainfo.org/

About Hypospadias Foundation

Hypospadias Foundation is a centre specialized for treatment of children with hypospadias. Our expertise in hypospadias makes us one of the best centres for hypospadias repair in the world. We treat children from more than 25 countries in the world and from all over India. Our dedication in this field has helped us achieve excellent outcomes. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra.

Dr A K Singal is an expert and top hypospadias surgeon in India. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.

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December 12 2024

Hormonal Testing Considerations in Hypospadias Repair: When and Why?

Hypospadias is a birth defect that affects 1 in 150 male babies. It occurs when the urethra, the tube that carries urine out of the body, doesn’t develop properly. Instead of opening at the tip of the penis, the opening is somewhere on the underside of the penis. In some cases, hypospadias may be associated with underlying hormonal issues that can affect the growth of the penis. While the exact cause remains unknown, some theories link it to abnormal hormonal development during pregnancy. In these cases, hormonal testing might be recommended before surgery to assess potential underlying conditions.

Hormonal Influences:

Testosterone: This male sex hormone plays a vital role in the development of the penis and scrotum. Low fetal testosterone levels might be a contributing factor to small penile size in some hypospadias cases.
Dihydrotestosterone (DHT): Testosterone is converted to DHT by an enzyme 5 alpha reductase. DHT is crucial for the formation of the urethra along the underside of the penis. An imbalance in DHT levels could potentially influence hypospadias development and associated small penile size.

At hypospadias foundation, we do the preoperative measurement of the size of the penis of all children with hypospadias. We check two parameters i.e Stretched penile length (SPL) and Glans diameter (GD).

The protocol which we follow at our centre is as follows:

1.	SPL <30mm	GD<12mm	Hormonal testing
2.	SPL<30mm	GD 12-14mm	Two doses of testosterone before surgery
3.	SPL>30mm	GD>14mm	Normal

When are Hormonal Tests Performed?

While not routine for all hypospadias cases, hormonal testing should be done in these situations:

Small phallus: The presence of a small phallus alongside hypospadias might indicate hormonal imbalances. If the size of the penis, SPL< 30mm and GD< 12mm then hormonal testing is mandatory
Severe Hypospadias: If the hypospadias is severe, affecting other genital structures or accompanied by undescended testicles (cryptorchidism), hormonal tests along with karyotyping might be recommended to diagnose a case of DSD (disorder of sexual differentiation)
Family History: A family history of hypospadias or other genital malformations could also warrant hormonal testing.

Which are the hormonal tests recommended in case of hypospadias?

hCG stimulation test is the hormonal test recommended in cases of hypospadias. On day 1, blood sample is collected and first dose of Inj hCG is administered. On day 2 and day 3, Inj hCG is administered. On day 4, serum testosterone and 5-alpha Dihydrotestosterone levels are measured. The dose of hCG is 3000IU/m²BSA. In this test pre hCG injection hormone (testosterone) levels are compared with post hcg injection hormone (testosterone and DHT) levels.

This test is interpreted as follows:

There should be a rise in testosterone levels after hCG injection (more than 2 times rise after hCG injection)
There should be conversion of testosterone(T) to dihydrotestosterone (DHT). The normal ratio of T/DHT is under 8 and is considered abnormal above 16. Between 8-16 is considered borderline.

If the hCG stimulation test shows normal rise in testosterone and normal T/DHT ratio, then the child is given two doses of testosterone in the preoperative period. This should effectively normalize the size of the penis for that age.

If the hcg stimulation tests shows increase in the levels of testosterone but inadequate conversion to DHT, then it implies that there may be 5 alpha reductase enzyme deficiency. These children do not have sufficient DHT in their body hence they will need DHT supplementation of to improve the size of the penis.

If the hCG stimulation test results are borderline, then we prefer to give two doses of Injection testosterone and assess the response. The ones who do not respond to testosterone may need DHT gel supplementation.

Rarely testosterone and DHT may not increase the size of the penis. The cause for this may be androgen insensitivity. In androgen insensitivity, the body’s cells are unable to respond to androgens, male hormones.

Hormonal analysis in hypospadias is important because it indirectly predicts the child’s future. If the hormone levels are normal, then there will be natural growth of the penis at puberty. If the hormone levels are abnormal then the child may need hormonal supplementation at puberty. But this decision is taken at puberty if the natural growth is inadequate.

Importance of Consulting a Pediatric Urologist:

If your child requires hypospadias surgery, a pediatric urologist will determine if hormonal testing is necessary based on the specific condition and individual factors. They will explain the rationale behind the tests and address any concerns you may have. Surgical results in a small penis are suboptimal with higher risk of complications.

At hypospadias foundation, we believe in complete care when it comes to hypospadias. Penile measurements in the OPD, preoperative hormone tests and supplementation if required and planning of surgery, every step is important to achieve our goal of successful hypospadias surgery with no complications. Dr Singal and Dr Shenoy are the best hypospadias surgeons for these reasons. Every child is assessed thoroughly and taken utmost care to yield excellent results.

Dr A K Singal is a highly experienced surgeon and is regarded as the best hypospadias surgeon in India and in the world for treating children and adults with hypospadias. If you are looking for a highly skilled and experienced pediatric urologist and hypospadias surgeon for yourself or your child, then Dr Singal is an excellent choice.

Dr Ashwitha Shenoy is an expert pediatric surgeon with a special interest in pediatric urology and hypospadias. Dr Singal and Dr Shenoy’s collaboration allows them to offer advanced surgical techniques and comprehensive care for patients.

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June 06 2024

Safe and Effective Anesthesia for Hypospadias Repair Surgery in Children

Hypospadias surgery is a procedure to correct the opening of the urethra on the underside of the penis. It is one of the most common pediatric urological surgeries. Ensuring your child’s safety and comfort throughout the surgery is paramount. Anesthesia plays a crucial role in achieving this goal.

Types of Anesthesia for Hypospadias Surgery:

 General Anesthesia: The most common approach, general anesthesia renders your child unconscious and pain-free. Medications are typically
administered intravenously (through an IV) or via inhalation through a breathing mask. The anaesthesia is usually short and there is no significant
effect on the child.

 Regional Anesthesia: Regional anaesthesia is one which works only in the specific area of the body. The regional anaesthesia used in hypospadias
repair is a caudal block, an injection near the tailbone for targeted pain control. This caudal block gives good pain relief for six to eight hours and
sometimes even up to ten hours after hypospadias surgery. Older children may feel tingly and numb in the lower limbs and may find it difficult to walk till it wears off, usually within first 12 hours

 Combined Anesthesia: Combining general and regional anesthesia offers the benefits of both: comprehensive pain management during surgery and a smoother recovery from general anesthesia.

The anaesthesia medicines chosen in children is such that there are minimal side effects and, we can resume oral intake as early as 1-2 hours after the hypospadias correction surgery.

Pediatric Anesthesiologists:

Anesthesia for hypospadias surgery is administered by a trained pediatric anesthesiologist, a medical doctor specializing in anaesthesia for infants and children and takes good care before, during, and after hypospadias repair surgery. They will meticulously assess your child’s health before hypospadias surgery, discuss anesthesia options, and choose the safest and most suitable approach for your child’s individual needs.

Communicate and Ask Questions:

Open communication with your child’s hypospadias surgeon & urologist and anesthesiologist is vital. Don’t hesitate to ask questions regarding the anesthesia plan and any concerns you may have. Feeling informed and involved in your child’s care can significantly ease anxieties.

At Hypospadias foundation, we have trained pediatric anesthesiologists who have managed more than thousands hypospadias correction repairs. From airway management, right medications to post operative pain relief we believe in a complete care of the child from pre surgery to post surgery. Safe and effective anaesthesia is necessary for good post operative recovery after hypospadias surgery.

Effective Pain Relief After Hypospadias Surgery

Pain relief is very important especially in a child because a cranky child makes the parents and the hypospadias surgeon anxious. After any procedure, it’s natural for your child to experience some discomfort but the discomfort should be manageable. Here’s a guide to effective pain relief after hypospadias surgery:

Doctor-Prescribed Medications:

 Pain relievers: After surgery we prescribe pain medications, often starting with acetaminophen(paracetamol) or ibuprofen. The medicines must be given as advised because good pain relief means a comfortable child and in turn leads to good healing after hypospadias repair.

 Antibiotics: To prevent infection, antibiotics are prescribed after hypospadias surgery. They must be continued till the catheter removal and
sometimes for a few days even after the hypospadias catheter is removed. Infection can destroy the entire hypospadias repair hence we need to be
vigilant and avoid infection at all costs.

 Bladder antispasmodics: The presence of a urinary tube can cause urinary bladder contractions. The only way to manage this is by prescribing anti spasmodic medicines. Hence after hypospadias surgery till the catheter removal, the child will be on anti-spasmodic medicines.

 Pain due to erection: Painful erections after hypospadias surgery occur in every child and are even more prominent in teenagers and adults. This pain can be quite bad due to swelling of penis and the presence of a urinary tube. Hence we prescribe a stronger painkiller diclofenac in the form of
suppository during these episodes of severe pain. This medicine gives good pain relief in times of extreme pain. For adults we also add more medicine to decrease painful erections at night.

At-Home Pain Management Strategies:

 Positioning: Encourage your child to rest comfortably, positioning themselves to minimize tension on the surgical area. This can be lateral or
supine position with pillow support.

 Distraction: Engaging your child in their favourite activities or games can help take their mind off any discomfort after hypospadias surgery

 Loose Clothing: Tight clothing can apply pressure on the operated site and cause discomfort to the child. Opt for loose-fitting clothing made from
breathable fabrics to avoid irritation.

 Dietary Adjustments: Prefer healthy nutritious food over processed food. Processed food does not have fibre and cause constipation in a child which in turn can cause bleeding at the operated site during straining. Maintaining hydration is also essential to prevent constipation.

 Hygiene: Maintain proper hygiene around the hypospadias surgical site as instructed by your doctor. Change inner diaper frequently when dirty and be vigilant for soling of dressing. If dressing gets dirty at any point, do visit the hospital and get a hypospadias dressing change.

 Activity Restrictions: Follow the doctor’s recommendations regarding activity levels to promote healing and prevent complications. Any vigorous
activities are generally avoided typically for 4-6 weeks after hypospadias surgery. Children can play at home and other board games comfortably.

Remember:

 Consult your Hypospadias Doctor: If pain seems excessive or worsens, consult your child’s doctor for further evaluation and possible medication
adjustments.

 Be Patient: Healing takes time after a hypospadias surgery. Be patient with your child and offer support throughout the recovery process.

At Hypospadias Foundation India, we have treated thousands of children and adults with hypospadias. Our approach to hypospadias repair includes
comprehensive care from preoperative to post operative period. Remember, every child heals at their own pace. By being prepared, informed, and supportive, you can help your child through this journey and ensure a successful recovery. Dr A.K.Singal and Dr Ashwitha Shenoy are rated as the best hypospadias surgeons in India. Their experience in the field of hypospadias makes them the best surgeons for hypospadias repair for both children and adults. If you need an opinion or consult us for your child, please do write to us at hypospadiasfoundationindia@gmail.com or fill up this contact form or visit us at the hospital.

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May 05 2024

Can chordee recur or come back after chordee correction or hypospadias repair surgery?

Chordee is a condition where the penis is curved downward. Most of the times it is associated with hypospadias but can occur without hypospadias. Chordee correction is very crucial step during hypospadias repair. Without chordee correction, urethroplasty should not be attempted because there will be a stress of the urethral passage and there is high risk of complications after surgery.

Chordee surgery is usually successful in correcting the curvature of the penis completely. However, there is a small chance that chordee can come back after surgery. This is called recurrent chordee.

Risk factors for recurrent chordee:

Incomplete correction of chordee: When the chordee is severe, it must be corrected completely during chordee correction surgery. If there is any residual chordee after chordee correction surgery, it will only worsen in the future.
Fibrosis during healing: After chordee correction, fibrosis can occur on the underside of the penis during healing process. Sometimes the fibrosis can improve with steroid massage but if it persists then recurrent chordee correction may be required. This fibrosis can be at the level of skin, tissue under skin or even urethra.
Due to flaps: Recently we have seen some cases where tunica vaginalis flaps were used for second layer cover during hypospadias surgery at other centres. Somehow the flaps didn’t heal well and they caused chordee to come back. Similar outcomes we have seen when a very tight urethra was made from prepucial flaps or koyanagi repair in first surgery.

Symptoms of recurrent chordee:

The common symptoms which children present with are downward bending of the penis, urine which goes backward and may have occasional pain during erections.

Adults with recurrent chordee may have pain during erection, inability to perform sexual intercourse, painful sexual intercourse and infertility

Treatment for recurrent chordee:

If you think you may have recurrent chordee or your child has recurrent chordee, it is important that you see a doctor right away. You need to visit a hypospadias surgeon or a pediatric urologist who has expertise in the field of hypospadias and chordee correction.

Chordee correction can be done by various methods. First and foremost, the cause for recurrent chordee has to be identified and then appropriate method is used to correct chordee. Chordee correction method differs for children and adults.

If a child presents with residual chordee due to incomplete chordee correction in the past, then the following methods of chordee correction are used: Complete degloving is done and chordee is assessed, if chordee persists even after degloving then the following methods are adopted. If the chordee is due to short urethra due to flaps or tunica vaginalis flaps, we divide them at this stage.

Recurrent chordee treatment in Navi Mumbai

Pre degloving and post degloving chordee assessment

(a) Dorsal tunica Albugenia Plication (TAP): If the chordee is less than 30 degree then it can be easily corrected by placing a non-absorbable suture at the site of maximum curvature on the dorsal side(upper side) of the penis. This will correct the chordee completely.

Post Degloving showed less than 30-degree chordee. 12’o clock dorsal tunica albuginea plication done. Chordee completely corrected by this plication.

No chordee noted after 12’o clock dorsal tunica albuginea plication

(b) Urethral plate division and Proximal urethral mobilization: If the chordee is more than 30 degrees then one of the reasons for persistent chordee is short urethra, in these cases we will have to divide the urethral plate ventrally and mobilize the proximal urethra. This will effectively correct chordee if it is due to congenital short urethra.

Urethral plate division and proximal urethral mobilization

(c)If chordee persists inspite of urethral plate division then urethral mobilization, ventral corporotomies are done. This will correct the chordee if the cause for chordee is due to disproportionate corporal bodies.

Three ventral corporotomies

(d) If none of the above measures can correct chordee then we perform a ventral lengthening procedure called as the dermal graft. Deep incision is given in the tunica on the ventral side at the site of maximum curvature and dermal graft is placed at the site. This method is adopted in cases of severe chordee.

Dermal graft

The chordee is corrected completely after the above steps of chordee correction.

2. If the child presents with severe chordee inspite of complete chordee correction in the past, then it is most likely due to ventral fibrosis. In these cases, along with some or all the above methods, removal of fibrotic tissues from the underside of the penis is important to correct the chordee.

Adults with recurrent chordee after previous surgery

In most of the adults at first we assess the fibrosis and degloving is done. If the chordee is still there, then we divide the urethral plate and mobilise it. Post this, if the chordee still persists, we can correct chordee completely by a method called as “16 dot plication”. In this method, 4 sutures are placed on either side of maximum curvature on the dorsal side, which will correct the chordee uniformly in an adult penis.

In most of the cases of recurrent chordee in addition to chordee correction, urethroplasty will also be required. In redo cases, chordee correction and urethroplasty will most likely be done in two to three stages and oral mucosa graft will be used in more than 95% of such cases. Only in few exceptional we may be able to repair everything in single stage.

About Hypospadias Foundation India:

Hypospadias Foundation in Navi Mumbai, India is dedicated to offering care and cure for chordee and hypospadias in children and adults. Set up in 2008, more than 3000 children and adults have benefitted from care and achieved best in class results for chordee and hypospadias. Dr A.K.Singal and Dr Ashwitha Shenoy, hypospadias expert surgeons at Hypospadias foundation have dedicated their lives to the art and science of hypospadias repair.

If you feel your child or you are suffering from recurrent chordee even after previous chordee correction, then do get it checked by an expert pediatric urologist or a hypospadias surgeon. Chordee correction surgery has good result when done in childhood than in adulthood. Do not hesitate to write to us or contact us

Contacting the Hypospadias Foundation:

Website: https://www.hypospadiasfoundation.com/
Email: hypospadiasfoundationindia@gmail.com
Phone:
- +916262840940
- +916262690790
- +919324180553(whatsapp and teleconsult)

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

Keywords: recurrent chordee, residual chordee, chordee repair, chordee repair surgery, chordee correction surgery, bent penis repair, best hospital for hypospadias in india, best hypospadias surgeon, hypospadias repair in india, adult chordee repair, dermal graft repair, 16 dot plication for chordee

To contact Hypospadias foundation, you can either write to us at hypospadiasfoundationindia@gmail.com or fill up this contact Form

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Author Archives: Dr. A.K.Singal

What is Hypospadias and is it necessary to repair it?

Is My Second Child at Risk of Hypospadias?

Understanding the Probabilities of second child with hypospadias

Moving Forward: Taking Charge

Additional Resources:

About Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation

Contact Form for Hypospadias Foundation