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

June 06 2025

Enhancing success rates in adult primary hypospadias surgery

In the last few years, we have been treating a lot of adults coming with unrepaired primary hypospadias wanting to get hypospadias repair surgery done. Adult Hypospadias repair surgery is a very different ballgame from child hypospadias surgery. Traditionally clinical outcomes for adult hypospadias surgery have not been as good with pediatric hypospadias surgeries as:

1. Chances of infection are high
2. Due to erections at night, chances of dehiscence are high

After having done hundreds of adult hypospadias surgeries, we can clearly see differences in adult hypospadias and children with hypospadias. Whether it is the size of penis, overall anatomy of tissues, pre-surgery preparation, intra-operative instruments and stitches or post-op care- everything is very different. Over the years, we have understood various steps which should be done to decrease risk of hypospadias surgery complications in adults. This has led to improved results in adult hypospadias surgeries.

Our Stepwise Adult Hypospadias Surgery and Care protocol:

1.Pre- surgery counselling: We make sure that expectations are set right. While hypospadias surgery can correct the curvature, cosmetic appearance and urine flow issues, hypospadias surgery cannot increase the size of penis or improve fertility. In our hypospadias clinic, after we have examined the adult hypospadias patients, we discuss what they want and the propose the outlined treatment plan.

2. Pre-surgery tests: Before hypospadias surgery is planned, we like to do blood tests for ruling our diabetes, check out any risks for anesthesia or any infection. We also like to do a urine routine test to check for any infection. Chest Xray and ECG test are done to make sure that the person is fit for anesthesia. We also take a consult from a physician to make sure that the
person is fit to undergo anesthesia for hypospadias surgery.

3. Pre-surgery preparation: We start a betadine scrub bath for cleaning pubic area twice daily 2 days before surgery. Pubic hairs are not shaved as shaving 1-2 days before surgery can lead to higher risk of infections. Typically, we trim the hair in the OT with a hair trimmer.

4. Surgery: General anesthesia with epidural block is given. All aseptic precautions are taken to prevent infection. Special microsurgery adult hypospadias instruments are used. Sutures used are also absorbable ones. Care is taken to handle tissues, nerves and blood vessels very gently. Dressing is done to support the penis and catheters are secured properly. Once the patient is out of anesthesia, we shift out to recovery room and thenward.

5. Post-Surgery care: We give IV antibiotics for 2 days and also open the dressing on day 5 to check for any infection. For some cases, we also advise hyperbaric oxygen therapy for 5-7 days. Catheter in adult urethroplasty is kept for a longer period as healing is slow. We typically keep two catheters – a suprapubic catheter and a urethral catheter. Both are kept for 3 weeks.

6. Follow-up: After urethral catheter removal, we typically clamp the suprapubic catheter and once the patient is passing urine from urethral well, we remove the suprapubic catheter after 2 days.

By following this protocol, our results in adult primary hypospadias surgeries have become the best in India and amongst the top centres in the world. Our success rates in Adult Hypospadias Surgery are over 95% in primary one or two stage repair with very less number of people needing further surgeries. At Hypospadias Foundation, a dedicated team of surgeons takes care of adult hypospadias. Dr A.K.Singal is a reputed and top hypospadias surgeon who has been doing hypospadias repair surgeries since 2006 and is rated amongst the best in the world for clinical results. Dr Ashwith Shenoy is a hypospadias surgeon who has deep experience in managing hypospadias. Both of them work closely giving best outcomes to adults with hypospadias. Given their team work and dedication to success rates in hypospadias, it is no surprise that people come from all over India and more than 20 countries to seek hypospadias treatment under their care.

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May 05 2025

Outcomes for adult hypospadias surgery: What surgery can and cannot achieve for you!!

Adult hypospadias surgery is fundamentally different from operating on a child. When we started hypospadias foundation in 2008, we started with an aim to help children with hypospadias and DSD get better outcomes. In 2015 we started getting lot of enquiries from adults with hypospadias. We realised that neither adult urologist or pediatric surgeons or plastic surgeons are equipped to deal with a congenital anomaly like hypospadias in adults. Whether it a primary non-operated hypospadias in an adult or a failed hypospadias repair in an adult, it is very different from the children. Hence, it is very important for the hypospadias surgeon to set the right expectation during the counselling session before hypospadias repair surgery. Unless the expectations are matched, no one is going to be happy after surgery.

Dr A.K.Singal and Dr Ashwitha Shenoy operating on a patient with hypospadias

What can adult hypospadias surgery accomplish:

1.Straight penis by chordee correction: If the person has a hypospadias with a bent penis, it can be fully corrected, and a straight penis can be achieved. We use a variety of chordee correction techniques like 16 dot plication Chordee correction surgery in an adult redo hypospadias using 16 dot plication in adults to achieve good outcomes.

2.Achieve urine opening at the tip: In almost all primary hypospadias, we are able to achieve an urinary opening on the tip of penis. In failed hypospadias or ones with previous surgeries (unless the glans -the head of penis- is damaged), with modern techniques, we are able to achieve opening on the tip. Rarely, if there is fibrosis or deformed glans due to previous surgery- we try to bring the opening as close to the head as possible.

3.Good Cosmetic result: In most of adult hypospadias, we are able to achieve a good cosmetic result with a straight penis, opening on the tip and a circumcised appearance. With modern stitches, good instruments and trained expert hypospadias surgeons, the stitch marks are also very less. Single stage hypospadias repair in an adult

4.Ease in intercourse: Some of the adults come to us with difficulty in intercourse due to chordee. Once chordee is corrected, the intercourse becomes painless and easy.

5.Standing up and passing urine: One of the chief complaints in hypospadias is that the urine goes backwards. Hence, the male has to sit to pass urine. This is especially true for proximal penile, penoscrotal or scrotal hypospadias. Once hypospadias is corrected, the urine goes forwards and the person can stand up and pass urine like a normal man. (urine stream pic)

6.Straight stream without spraying: Most of unoperated or failed hypospadias repair come to us with spraying of urine. This happens when the urine hole is not on the head, the urine doesn’t get a proper direction to form a nice stream. Once the hypospadias is corrected, urine starts coming in a normal single stream from the head of the penis and directed forwards without spraying.

7.Passage of urine from one hole: Some of the failed hypospadias cases may have multiple holes due to urethral fistulae. Due to these the person may be passing in 2, 3 or more streams. We have seen cases where the person was passing urine like a watering can due to multiple holes. This can all be corrected with successful adult hypospadias surgery by an expert surgeon.

8.Healthy mental state: We have seen lot of young adults, who feel inferior and incomplete due to a deformed penis because of hypospadias. They often are hesitant to establish relations with opposite gender. Once repaired with a good result, these men report higher mental self esteem and comfort in establishing healthy relationships. If the depression and anxiety is severe, it is a good idea to discuss with your surgeon and take some psychology help before and after surgery,

What adult hypospadias surgery cannot accomplish:

1.Increase in penis size: Hypospadias surgery leads to correction of anomaly but not an actual increase in size of penis. In some cases with severe chordee, unrepaired penis may look small due to chordee. Once we correct such cases, the penis may look longer due to straightening of the penis.

2.Solve premature ejaculation: Premature ejaculation is not related to the hypospadias and hence surgery can’t solve this. For such issues we refer the cases to adult urologist for treatment.

3.Erectile dysfunction: Some men with hypospadias come with erectile dysfunction, generally this is not related to hypospadias itself. It may be psychological or due to some other anomaly. Hypospadias by itself doesn’t cause erectile dysfunction and repairing hypospadias doesn’t improve it either. For such issues we refer the cases to adult urologist for treatment.

4.Cure infertility: Hypospadias may cause difficulty in intercourse if there is severe chordee but generally doesn’t cause infertility. Hence, if the sperm count is low or poor, doing a surgery will not solve this. For such issues we refer the cases to adult urologist for treatment.

It is important that adults with hypospadias discuss these issues threadbare with their treating hypospadias surgeon before surgery. We also take help of a clinical psychologist or an adult urologist whenever needed before surgery to set the right expectations. At Hypospadias Foundation India, we are dedicated to helping adults and children with hypospadias get the right diagnosis, full counselling, expectation setting and surgical treatment with empathy. With both the surgeon and the patient aligned, great outcomes and happiness can be achieved.

Dr A.K. Singal is rated as the best hypospadias surgeon in the world for adult hypospadias surgery. Dr Ashwitha Shenoy is a well-trained pediatric urologist and hypospadias surgeon working with Dr Singal. Together as a team both of them treat hundreds of adults and children with hypospadias from across India and the world every year with best care and results. With advancing experiences, the complications of adult hypospadias have decreased significantly, and success rates are above 96% at Hypospadias Foundation.

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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.

Contact Form for Hypospadias Foundation

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Author Archives: Dr. A.K.Singal

Contact Form for Hypospadias Foundation

What can adult hypospadias surgery accomplish:

What adult hypospadias surgery cannot accomplish:

Contact Form for Hypospadias Foundation

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