My child is very naughty!! How will I manage him after surgery!! – Putting on the parents cap

Understanding postoperative problems after Hypospadias Surgery (Urethroplasty) in children

This is the second most common question asked by the parents when I counsel them for surgery for hypospadias!

After Hypospadias Surgery (urethroplasty), this is often the most important management issue for the parents – though more for the mother than for the father. We as clinicians may often focus more around the medical issues – the pre-operative checklist, the steps and arrangements for hypospadias surgery, the stitches, antibiotics, anesthesia and dressings. But what about the rest of the issues – what about the child himself, the issues which parents face may face 24/7 like pain, food, tantrums, diaper changes, naughtiness management etc. I guess it is time that we doctors should see 360 degrees around whatever goes in treating a child with hypospadias. We should attempt to cross the line to the other side and think like a parent and then should be open to discuss all these questions and answer them placing ourselves in parent’s shoes.

So here are the facts as we see them:

1. Pain: The main concern after surgery is often the pain. Since penis is very sensitive organ with intricate nerve supply, sometimes there may be significant pain for the first 3-4 days. But pain is also a variable symptom as intensity may vary from one child to another. Sometimes children who have undergone severe hypospadias repairs lasting 3-4 hours do not complain of pain at all and are running around pain free the next day while some children with a minor hypospadias repair may complain of a lot of pain. We usually prescribe enough pain killers and antispasmodics to care of pain as well as bladder spasms but still the kids may be a bit irritable for the first couple of days.
2. Diet & feeding: We generally allow children liquid feeds 3-4 hours after surgery and then gradually advance to a full diet by evening itself. Sometimes the children may be a bit sleepy and fussy for a few hours after surgery but eventually most of the kids are on full normal regular diet by the evening of hypospadias surgery.
3. Diaper care: Children are kept in a Double Diaper Care Program after surgery to avoid catheters hanging with a bag. A small hole is cut out into the front side of the inside diaper and the urinary catheter is taken out through this to drain into the outer diaper. The inner diaper thus needs to be changed whenever the child passes stools or twice a day atleast and outer diaper whenever it gets wet with urine. Double diaper care allows the child to move around, walk or play without the bag hanging to his waist or leg. Also, the chances of a catheter getting accidentally pulled out are much less when it is draining within the diaper.
4. Medicines: There are about 4-5 medicines in liquid syrup form which are administered to the baby after hypospadias surgery. These are an antibiotic, a pain killer, an antispasmodic and a medicine to prevent side effects (acidity) due to pain killers. In bigger children, we also prescribe diazepam to prevent painful erections. Medicines are usually given for 7-10 days after surgery.
5. Catheter care: Catheter is a plastic tube which is placed into the bladder and thus supports the new urethra. Catheter drains the urine continuously into the diaper and allows the stitches to be dry during the critical phase. The catheter is kept for a period ranging from 5 days to 12 days depending on the type & complexity of repair.
6. Dressing issues: At the end of hypospadias surgery a soft gauze dressing is applied on the penis and this is generally removed after 5-6 days of surgery. Sometimes there may be a small amount of blood staining after surgery or dressing may slip off after 2-3 days but this will not affect the outcome at all. After dressing is removed, the penis may look swollen and reddish as penis is an organ which swells frequently after surgery. The swelling goes away on its own in 1-2 weeks time and raw areas also heal up very fast.
7. Minor bleeds: Penis being a very vascular organ has a very rich blood supply. There may be a minor bleed from the head of the penis in the first 2-3 days after hypospadias surgery. This generally presents a spotting on the diaper or the dressing.
8. Cosmetic outcome: The final cosmetic aim of hypospadias surgery is to give a circumcised appearance with an absolutely straight penis. The meatus should be at tip with a slit like normal appearance. The final cosmetic outcomes will take about a month after surgery to be seen.
9. Cleaning and bathing: Children are not allowed formal full body bath for a first 4-5 days after surgery till the time the dressing is in place. Sponging can be done taking care not to wet the dressing. Once the dressing has been removed it is advisable to give warm tub baths twice a day for the next two weeks. This allows the warm water to wash away all the clots and debris and swelling also reduces. After bathing, the penis should not be dried while rest of the body can be dab dried. Ointment is applied and then the diapers can be placed.
10. Follow-ups: Follow up is done day 5-6 after Hypospadias surgery and then at catheter removal, one week, one month and 3 months later. Healing, caliber of the new urethra is assessed at every follow-up. This may include a gentle calibration with a catheter by the doctor in the clinic itself.
11. Naughtiness management after hypospadias surgery: This is the most difficult question to answer as there is no single answer to this issue. To me all the kids are naughty and all of them manage fairly well after surgery. I haven’t heard too many parents cribbing after surgery that they had an issue with managing the kids. There are so many ways to keep the kid happy after surgery like toys, books, video games or just being around.