About Hypospadias Archives - Page 3 of 5

August 08 2020

Hypospadias Guide for Pediatricians and Healthcare Professionals

Hypospadias foundation is an organization that aims to disseminate thorough & credible information and provide personalized medical care for patients having Hypospadias and DSD. Caring for children with hypospadias/ DSD requires a lot of commitment from the family as well the health care team managing these children. Pediatricians and healthcare professionals can find valuable resources in the Hypospadias Guide for Pediatricians and Healthcare Professionals.

What is hypospadias and what are the types of hypospadias?

Hypospadias is a congenital condition where the opening of the urethra (meatus) is on the underside of the penis rather than on the tip. It may be associated with abnormal curvature of the penis (chordee). The different types of hypospadias are glanular, coronal, distal penile, mid-penile, proximal penile, penoscrotal, scrotal, and perineal hypospadias. For pediatricians and healthcare professionals, understanding this condition is vital, and a comprehensive Hypospadias Guide can provide essential insights and guidance in managing cases effectively.

How is Hypospadias diagnosed?

Hypospadias should be suspected in a newborn when the prepuce is incomplete, meatus is on underside and there is bent penis (chordee). Ideally, a pediatrician should be able to clearly diagnose hypospadias clinically at birth. In some cases, there may be doubt especially in minor hypospadias. In such cases, it may be good to consult a pediatric urologist or a surgeon around 3-6 months of age.

When do you suspect DSD?

DSD is suspected when the hypospadias is severe (Scrotal or perineal), when hypospadias is associated with small size of the penis (microphallus) or when the hypospadias is associated with one sided or both sided undescended testes. In such cases investigations in the form of karyotyping and hormonal evaluation is necessary.

When should a child with hypospadias be referred to a pediatric urologist or a pediatric surgeon?

In children with isolated hypospadias, the ideal age for a surgeon to see them is around 3-6 months of age. For children with suspected DSD or small phallus or associated undescended testis, patients should be referred in the first 2-3 weeks of age itself for hormonal and DSD evaluation.

What is the ideal age for surgery for Hypospadias?

We recommend Hypospadias repair in boys between 6months to 15 months of age if they have a good weight and there is no other congenital anomaly. In some preterm babies or babies with a delayed growth, other anomalies – a second window of opportunity is between 3-5 years of age.

What are the Goals of Hypospadias surgery?

Good functional and cosmetic outcome in form of a straight penis, normally located urinary opening at tip of penis, ability to pass urine like a normal child with thick single forceful stream.

Do all Hypospadias need surgery?

Minor hypospadias like glanular hypospadias and coronal hypospadias can be left alone if the meatus is of good caliber, urine flow is in good stream & forwardly directed and there is no chordee. Otherwise, all hypospadias which are distal penile or more proximal in location or have any chordee should be repaired.

What are the tests needed before Hypospadias surgery?

For isolated hypospadias- only simple blood tests and fitness assessment are required before surgery. If there are any associated abnormalities like undescended testis then further detailed testing may be required to rule out DSD. Hormonal tests may be required if the size of the penis is small for age.

How is the Hypospadias surgery done?

Hypospadias requires a corrective surgery called Urethroplasty which involves- correction of penile curvature (Chordee) and creation of new urethra (neourethra) to the tip of penis. Many different techniques for surgery are available and a particular technique is used based on the type of hypospadias/ severity of defect. Some children may require pre-operative hormone injections to improve the size of penis and facilitate and improve surgical results.

Is the surgery done in a single stage or requires multiple stages?

The deciding factor for single or staged repair is the severity of chordee. In cases of mild chordee single stage repair is possible. Complication rates of single stage surgery are less than 10% in good centres such as Hypospadias Foundation and less than 5% may need a second surgery. Staged Hypospadias repair remains an option in very severe hypospadias and those with very severe chordee but such cases constitute less than 10% of all cases.

What is chordee correction and why is it essential?

Chordee is defined as abnormal ventral curvature of the penis. Chordee, when left uncorrected or partly corrected, can result in painful erection and difficult sexual intercourse. As a first step of any hypospadias surgery, chordee assessment is done after complete degloving. Based on the degree of chordee, various methods are followed for chordee correction. The various methods include dorsal tunica albuginea plication, urethral plate division and proximal urethral mobilization, fairy cuts, corporotomies, and in severe cases of chordee, a dermal graft for ventral penile lengthening may be required. Pediatricians and healthcare professionals can find detailed guidance on managing hypospadias in the ‘Hypospadias Guide for Pediatricians and Healthcare Professionals’.

What is a post-surgery course and follow-up?

Most of the children are discharged on the same day in the evening after surgery. Some children with severe hypospadias or failed previous surgeries elsewhere may require 1-2 days hospital stay for antibiotic injections and pain relief. Typically, we train the parents to take care of the catheter in a double diaper fashion so that there is no urine bag hanging out. We do not advise any bed rest and children are free to walk around and play the next day of surgery.

At the time of discharge – an antibiotic syrup, analgesic (pain killer) and a medicine to control bladder spasms is commonly prescribed. Dressing is normally removed on day 7 and catheter on day 7-10 depending on the type of repair. After that a follow up visit is needed at 1 month/ 3 months and 1 year after surgery. We also like to see the children at 7-8 years and 12-15 years of age.

What surgeries are done for failed hypospadias?

In expert hands the rate of complications should be less than 10%. The common complications which can occur after hypospadias repair are urethrocutaneous fistula, urethral diverticulum, recurrent chordee and glans dehiscence. There are good techniques available to correct these complications. In children with failed hypospadias after multiple failed surgeries, oral mucosa graft urethroplasty is an option. At hypospadias foundation the results of oral mucosa graft repair are excellent with minimal complications.

Does hypospadias cause infertility?

Isolated hypospadias has not been known to be associated with infertility. Sperm counts of children who were operated on in childhood were shown to be normal. If there is associated undescended testis, then chances of infertility are higher in men with a history of hypospadias. Also, in men with chordee, intercourse may pose technical challenges, hence chordee correction is a must to provide long term normal sexual function.

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

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

January 01 2020

Is foreskin reconstruction possible in hypospadias?

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Hypospadias is a common urological problem seen in children. The characteristic feature in hypospadias is excess foreskin on the front side of the penis with absent foreskin on the underside with abnormal position of meatus. The common procedure for hypospadias involves using the excess foreskin on the front side of the penis to reconstruct the urethra(urethroplasty). Hence post urethroplasty the penis has a circumcised look.

One of the most frequent questions which Parents ask is – Can the foreskin be reconstructed and retained during urethroplasty and avoid circumcision?

Well the answer is not so straightforward. Traditionally hypospadias repair aims at bringing the meatus to the tip with circumcision as a part of the procedure. But in some cases, with newer techniques, preservation of prepuce is a possibility but not in all the cases.

Case selection is crucial when we consider foreskin preservation and reconstruction (preputioplasty) because it is associated with its own set of complications. Expectation of parents should be discussed prior to considering this procedure. The ones who do not want a circumcised look of penis for their child, we tend to offer prepucioplasty provided the procedure is possible. Hence in a few selected cases of hypospadias circumcision may be avoided. We at hypospadias foundation have operated a few cases of distal hypospadias and foreskin reconstruction(prepucioplasty) was successfully done in these children.

Here are some of the common questions/answers about foreskin reconstruction which will help the parents to know more about foreskin reconstruction in hypospadias.

What is the procedure of foreskin reconstruction?

Reconstruction of foreskin is called “prepucioplasty”. Following urethra reconstruction- “urethroplasty”, the prepuce is incised and closed in 2 layers- outer and inner skin separately.

What is the procedure done when we do not want foreskin reconstructed?

When prepucioplasty is not possible we rotate the excess foreskin from the front side of penis and use parts of it to reconstruct the urethra(urethroplasty). Following this procedure, the penis looks circumcised.

Which cases are ideal for foreskin reconstruction?

Children with minimal defect of foreskin on the underside of penis, distal hypospadias with no abnormal curvature (chordee) of the penis can be offered foreskin reconstruction. This procedure can be considered in parents who want to avoid circumcision for their child.

When do we avoid foreskin reconstruction?

Pre- operatively if the hypospadias is of moderate or severe type and if the foreskin defect is significant then we do not consider foreskin reconstruction. During the surgery if the curvature of the penis(chordee) is found to be significant we tend to avoid prepucioplasty.

What is the postoperative follow up in cases of foreskin reconstruction?

Following foreskin reconstruction in hypospadias, the catheter will stay for 7-10 days. During follow up, we advise the parents to gently start retracting the prepuce after 3 weeks and apply a lubricating antibiotic gel. We advise parents not to retract the foreskin at home in the initial few weeks. Following 4 weeks after surgery, we advise application of a steroid cream for a period of 4 weeks to prevent secondary adhesions.

What are the complications of prepucioplasty?

Prepucioplasty is associated with its own set of complications. Early complications of prepuicoplasty involves prepucial dehiscence or incomplete retraction of the prepuce. Late complications involve secondary phimosis. Developing a fistula is also a known complication because of inability to provide dartos cover for the urethroplasty.

Here are the pre- and post-operative images of Master AP, 7-month child who underwent distal hypospadias repair with prepucioplasty.

Notice the ventral defect in prepuce is small in this case of distal hypospadias

Completed Foreskin Reconstruction (prepucioplasty)

About Hypospadias Foundation:

Hypospadias foundation is a centre which provides personalized care for children and adults with hypospadias. It is the best hospital centre in India and world for surgical treatment for hypospadias in adults and children. Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries of hypospadias are performed at MITR hospital.

Dr A K Singal and Dr Ashwitha Shenoy are expert surgeons for Hypospadias in India. Working together as a team they have achieved excellent outcomes in primary and failed hypospadias in children as well as adults.

For appointment with Dr Singal or Dr Shenoy, kindly contact us at the contact details given below.

MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India- Call for appointments: +91-2227743558/ 27744229/ 39/69 and +91-9324180553.

MITR Clinic: C1/8 Ground floor, Sector-2, Vashi, Navi Mumbai, India – Call: +91-9324502572

January 01 2020

Dr A.K.Singal presents his work at Hypospadias World Congress at Childrens Hospital of Philadelphia, USA

Hypospadias Foundation starts Clinic for Hypospadias Treatment & Surgery in Bahrain

Dr A.K.Singal was an invited speaker at Hypospadias World Congress at Children’s Research Center at Children’s Hospital of Philadelphia, USA, held between 30^th October 2019-1^st Nov 2019. Dr Singal presented four papers on hypospadias treatment and moderated scientific sessions during the conference.

The conference saw participation from more than 150 pediatric urologists and hypospadias specialists from across the world. The conference solely focussed on hypospadias. Various aspects of hypospadias were discussed such as etiology, diagnosis, hormonal tests and supplementation (testosterone injections), surgery techniques and complications/ results of hypospadias surgeries.

Dr A.K.Singal

Dr Singal with Dr Long & Dr Zaontz

Dr Singal presented the following lectures and papers in the World Congress:

Buccal inlay graft for failed hypospadias- Dr Singal showed technique of buccal (oral) mucosa graft inlay surgery and its results in failed hypospadias cases.
Considerations in adult hypospadias repairs- Adult hypospadias are difficult to manage especially if the surgery done in childhood has failed. Dr Singal showed innovative surgery techniques for such adult hypospadias cases for best outcomes.
Reimagined Byar’s flaps for staged hypospadias repairs- For hypospadias with severe chordee, it is important that the penile curvature gets fully corrected in first stage and then second stage surgery is done for bringing the urethra to the tip of penis. In expert hands the results of two stage surgery for hypospadias with severe chordee is very good. Dr Singal showed finer nuances of surgery to achieve best results to the audience.
Parental Awareness survey for families with hypospadias: Families of children or adults with hypospadias are often not fully aware of the extent of disease and what it means in the long run. Dr Singal and his team conducted a study of 150 families to understand about their concerns about hypospadias and their knowledge level about the disease/ surgery.

Overall the three-day conference resulted in great mutual exchange of ideas and also helped younger generation of surgeons learn from eminent faculty from all over the world.

April 04 2015

What is chordee (bent penis) and why do hypospadias have chordee? How is chordee correction surgery done?

Chordee means that the penis is bent (curved penis). Penis mostly gets bent downwards hence it is called ventral chordee and is seen commonly seen in children with hypospadias. In children with other type of anomaly which is much rarer than hypospadias called epispadias the penis may be bent upwards, it is called dorsal chordee. Hypospadias is atleast 20-30 times more common than epispadias, hence when someone uses the word chordee it is by fault supposed to mean ventral chordee as seen in hypospadias.

Why does chordee happen?

When the penis is getting formed between 8-12 weeks of pregnancy, the urethra (urinary passage) also starts getting formed from the base of penis to the tip of penis. This happens gradually under the 3influence of male hormones produced by the testis. All around urethra, a special tissue called corpus spongiosum is also formed through which the urethra runs. The two cylinders of tissue called corpus cavernosa are also formed. Together equal sizes of spongiosum and two cavernosa cylinder are responsible for a straight penis. When the urethra is short as in hypospadias, the spongiosum tissue is a3lso short, the skin and dartos tissue under skin is also short and sometimes the corpora can also be curved. Hence chordee results from this shortage of these tissues on underside of penis.

Do all hypospadias have chordee?

Chordee is seen more than 50% of all hypospadias but this also depends on the severity of hypospadias. Generally, the more severe the hypospadias is, higher the chances of chordee. Hence, chordee is more common in scrotal hypospadias than distal penile hypospadias. This is a generalization and it is not true in all cases as we have seen lot of cases of chordee without hypospadias and also minor hypospadias having a major degree of chordee.

How is chordee checked and graded?

Chordee can sometimes be seen by the parents when the child has an early morning erection which happens even in small babies. Generally we tell the parents to click the picture from the side to document the chordee degree. Chordee must always be checked during hypospadias surgery by doing an artificial erection test. This is infact a mandatory test for all hypospadias and the most important thing to be taken care of during hypospadias surgery. If chordee is not checked and left untreated, it can create lot of issues in adulthood and need surgery again which is much more difficult in adulthood. Chordee is graded in degrees like 30 degrees, 45 degrees or 90 degrees or also as mild, moderate or severe.

Does chordee always need surgery repair?

A straight penis is important to have straight stream of urine as well as for having normal sexual intercourse. Hence, if the penis has anything more than 15-20 degrees of bend should be corrected.

How is chordee repair surgery done?

Degloving of penis: In any hypospadias surgery or chordee repair surgery, the first step is called degloving of penis. Degloving means that the penis skin is taken down till the base of penis by a circular incision around head of penis while saving the opening of hypospadias and urethral plate. Generally, there are some abnormal tissues around base of penis which cause chordee and once these are divided chordee gets corrected in most cases. Then a tourniquet is applied on the base of penis and saline solution is injected into the head of penis or corporal bodies. This is called artificial erection test and allows the hypospadias surgeon to assess the degree of chordee.
Tunica albuginea plication: If there is still chordee then further steps need to be done to correct chordee. If the chordee is mild, then we perform tighten the top side of penis with a non-absorbable stitch to straighten the penis.
Division of urethral plate: If the chordee is still severe then a cut needs to be given to divide the urethral plate between hypospadias opening and the head of penis.
Dermal graft for chordee correction: Chordee is again checked and if it still severe then corpora needs to be lengthened by placing a dermal graft on underside of penis. In case a dermal graft is placed, then a single staged repair can’t be done and a staged hypospadias repair is done.

It is important for a hypospadias surgeon to make sure that the chordee is completely corrected during hypospadias surgery. It requires experience to do a stepwise assessment of the chordee in every individual case and then proceed with chordee repair as detailed above. The importance of having a straight penis cannot be overemphasized.

About the author:

Dr A.K.Singal during Hypospadias surgery

Dr A.K.Singal is a renowned Pediatric urologist and is one of the best & most experienced hypospadias surgeons across India and world. His deep interest, research, knowledge has helped hundreds of children and adults with hypospadias achieve a satisfactory cosmetic and functional results of hypospadias. Dr Singal is available in Fortis Hospital in Mulund Mumbai, Jupiter hospital in Thane, Fortis Hospital in Vashi (Navi Mumbai) and MITR Hospital & Hypospadias Foundation in Kharghar, Navi Mumbai, India. To reach him you can send him an email at hypospadiasfoundationindia@gmail.com or fill up this form:

Contact form for Dr Singal

Also, you can call up Dr Rajkumar, Dr Singal’s assistant and Coordinator of Hypospadias Foundation on +91-9821261448

Video of Glanular Hypospadias with chordee surgery repair by Dr A.K.Singal