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May 05 2013

Increasing incidence of Hypospadias

Author Dr. A.K.Singal Categories About Hypospadias

Hypospadias is recognized as a pediatric urological disorder, the incidence of which is on the rise over the last two decades. While researchers and clinicians agree that the detection and diagnosis rate of hypospadias has increased due to increased awareness, it is also certain that there are other factors which are contributing to the increased incidence of hypospadias.
The last few studies have noted the incidence of hypospadias to be almost 1/150 newborn boys. This is substantial as compared to what was reported to be 1/250 boys two decades back.
To understand what leads to higher incidence of hypospadias we have to understand in a simple language how Hypospadias happens. During the critical phase of sex development in the baby during pregnancy – at around 8 weeks both the male and female sexual organs look similar. Between 8-14 weeks, under the influence of male hormones produced by the testis (Testosterone and Dihydrotestosterone, also called androgens) these organs develop into male organs. These hormones cause the genital tubercle to enlarge and become a penis and at the same time the urinary passage (called urethra) starts developing on the underside of the penis and closes like a zipper from the bottom to the tip of penis. All this is a very intricate coordinated activity and guided by levels and actions of male hormones. Blockage of action of these hormones or lower levels in this critical phase lead to an incomplete urethra resulting in hypospadias. Thus, the urethra falls short of the tip and urethral opening remains on the underside of penis.
Recent research has shown that the rising levels of chemicals in environment so called Endocrine disruptors have been responsible in some ways for this rise in the incidence of hypospadias and other reproductive anomalies such as undescended testis, low sperm counts and testicular cancer. These chemicals come from pesticides, colouring agents, dyes, hair sprays, plastics used in cars, bottles etc. They are all around us and it may take us many years to see their full blown effect on human bodies. Even hormonal treatment for infertility such as IVF, smoking and excessive analgesic use during pregnancy has been shown to have increase the risk of hypospadias. In an environment loaded with pollution and unknown synthetic chemical residues, we can never ascertain fully how the cumulative effect of all these agents affects the gentle developing organs of the baby.
We recently conducted the largest study yet in India about finding out the incidence of hypospadias and undescended testis in India. We found that incidence of undescended testis has increased to almost 5% and hypospadias 1/126 babies in India. Earlier reported incidence for undescended testis was 1.6% in 1971, so it has almost tripled in last 40 years. Hypospadias incidence has not been reported in India yet.
Extrapolating these figures, there will be around 110,000 babies born with Hypospadias every year in India and they will need counseling and proper treatment. Similarly, almost 7 lakh (700,000) babies will be born with undescended testis and almost 30% of these – almost 2 lakh babies (200,000) will need surgery for undescended testis every year. These numbers are not small by any stretch of imagination and call for further research and awareness among general public, governmental organisations as well as doctors.
Dr A.K.Singal, Pediatric urologist & Hypospadiologist, presented these findings at European Society of Pediatric Urology Annual Congress in Genoa, Italy in April 2013. The study was very well appreciated and we won a prize also for it.
At Hypospadias Foundation, we have committed ourselves to excellent clinical care of children with Hypospadias but equally importantly towards meaningful clinical research in the field of Hypospadiology also. In India typically we follow data from the west as we do not have means to collect our own data or just that our priorities towards care for the large population are so huge that we do not have time/ resources for research. Since Hypospadias Foundation is an autonomous body, we have made research our important goal and made it a missionary zeal to collect our own data within India, learn from our own data and then share the research results with the rest of the world.
Medical Science moves forwards by doing clinical work and also analyzing that we are doing today is better than what we did yesterday. But if we can use scientific research tools to find out why hypospadias happen, why are they increasing and what can be done to decrease the incidence – that will be the most fruitful use of science. Prevention is always better than treatment.

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    December 12 2012

    Dressings after hypospadias surgery – everything the parents should know about!

    Author Dr. A.K.Singal Categories For Parents and Patients

    Why is dressing needed after hypospadias surgery (urethroplasty)?

    As after any surgery, a dressing is required after hypospadias repair as well and the reasons for this are many.

    • The dressing helps to prevent infections by creating a physical barrier as well as supports the penis in the healing phase.
    • Penis is an organ which has a tendency to swell up after surgery or any trauma and thus a dressing helps to support the organ in the healing phase after hypospadias surgery.
    • Besides these two major goals, some surgeons use the dressings to prevent bleeding after surgery but with the refined techniques and more experience, bleeding has become less common issue surgery and we at hypospadias foundation generally use a very loose dressing as prevention of bleeding is generally not the goal for the application of dressing.

    When we were in surgical training, we had a standard firm elastocrape dressing which used to be applied tightly and was resultantly difficult to remove. The advantage, though, was that it would remain in place without the risk of getting dislodged. On a personal front, as a resident doctor asked to remove those bulky sticky dressings, I was never happy with the dressing as it was difficult to apply, difficult to remove and I felt that it would cause too much of pressure on the healing tissue at the cost of impairing circulation. Also the healing area will not get air to breathe. I was worried that this may result in poor healing as well.

    Over the last few years though the primary goals of dressings have remained the same, the dressing after hypospadias surgery itself in our practice has become very easy to apply and remove.

    What we use is the following:

    At the end of hypospadias surgery, we put a transparent cling wrap kind of dressing called – Tegaderm film- on to the penis – the operated site. This is light in consistency, does not stick to the tissues, is easy to remove and it allows passage of air through it thus aiding in healing.

    Over the Tegaderm film, we apply a couple of rolls of thin white gauze just to support the penis and this layer is kept loose and just functions as a soft scaffolding.

    A small piece of sticking tape called micropore is applied to hold the gauze piece and the catheter in place and this step finishes the dressing.

    In some children, if the dissection has been extensive into the scrotum or the penis length is short we apply a sandwich type of dressing over the whole area instead of a rolled dressing.

    Double diaper care- finally the catheter is brought out through a small hole in the inner diaper and left to drain in the outer diaper. Double diapers also help in keeping the area snug and dry during the healing process while allowing the children freedom of movement.

    We believe a loose dressing after hypospadias surgery allows good blood circulation to operated area after surgery and thus faster healing. Also, we have observed that the pain is much less with this type of dressing. This dressing is also very easy to remove in the outpatient department during follow up.

    What can go wrong with hypospadias dressings?

    Dressings can get dislodged fairly frequently after hypospadias surgery. If this happens during first 2-3 days we like to do the dressing again in clinic. But if this happens after 3 days, we just remove the dressing completely and apply antibiotic ointment on the operated area 3-4 times a day and at every diaper change.

    When do we remove the dressings

    We generally remove the dressings on day 5-6 but in certain distal hypospadias we like to remove the dressings along with the catheter on day 7 after surgery. Removing them together avoids one opd visit for the family.

    How are dressings removed after hypospadias surgery/ urethroplasty?

    Dressings are removed in the outpatient unit by the junior doctor or the treating surgeon by gently teasing them out. Sometimes normal saline is used to ease out the dressings by making them wet. We have seen that tegaderm based dressings slip out fairly easily in clinic. The only caution to make sure that the catheter is not accidentally pulled up while loosening the dressing.

    What happens if there is bleeding into the dressing?

    Minor bleeding after hypospadias surgery is fairly common and happens as penis has very robust blood supply. Generally this occurs as a small amount of blood spotting or drops of blood at the tip of penis. If the bleeding stops by itself, nothing needs to be done and this is generally the case. If the bleeding is more in quantity, we ask the parents to visit us and a tighter dressing may need to be applied.

    What happens if there is urine leakage into the dressing?

    Small amount of urine leakage by the side of the catheter into the dressing is common. If there is lot of urine leakage by the side of the catheter then this means that the catheter may be blocked. The surgeon can then flush the catheter to relieve the block and the leakage will stop.

    What happens if there is potty staining of the dressing

    Sometimes the children may have loose motions after hypospadias surgery due to side effects of the antibiotics. These may then leak and stain the dressing. In such a case you should wash away the stools and visit the Hypospadias Foundation/ Mitr Hospital to get the dressing changed or removed. If dressing is left potty stained for long, this may allow the bacteria in potty to cause infection in the freshly operated hypospadias.

    What care to take after removal of dressing

    Child can be given warm tub bath twice a day and an antibiotic ointment should be applied on the operated site 4-5 items per day.  Inner Diapers should be changed at least 2-3 times per day and outer ones as soon as they are full with urine.

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      November 11 2012

      My child is very young! Is it a safe age to do hypospadias surgery?

      Author Dr. A.K.Singal Categories For Parents and Patients

      One of those questions which parents often ask and which is probably one of the most difficult to answer. But none the less the Question requires its due answer! To start from the basics, Hypospadias is a condition which is generally diagnosed immediately after birth by the pediatrician / neonatologist. The anomaly is very evident by an incomplete prepuce (foreskin), bare glans (head of penis), often a bent penis (called chordee) and misplaced urinary opening. Mostly it is an isolated anomaly but sometimes there may be an associated undescended testis with hypospadias. Since hypospadias is diagnosed at birth, ideally the child should be referred for a surgical opinion from a pediatric urologist or a surgeon trained in doing hypospadias surgery in the first few months of life. Early referral helps as the parents can then plan their lives around treatment of hypospadias. Hypospadias is a problem that always requires surgery called urethroplasty except in very minor varieties such as glanular hypospadias without chordee. It has been shown in multiple clinical studies that children do better when they are operated for hypospadias in infancy itself, ideally around 6-12 months of age. The reasons for these recommendations are multiple:

      1. At this young age the tissues are very soft and tend to heal very well after surgery.

      2. Emotional and psychological issues around getting operated in genital area are non- existent at this age.

      3. Once the surgical result has been good – children at a later age don’t even notice or come to know that they ever had hypospadias as there is hardly anything to differentiate these children from other children. For most of the distal and moderate hypospadias, penis after surgery just looks like a circumcised penis. There is also a debate whether these children should actually be told that they had hypospadias earlier on in their life.

      4. Incidence of wound infection, post surgery bleeding etc are much less at younger age as bacterial colonization is much less.

      5. Post- operative pain and erections are less common at this age.

      6. Management of a small child in diapers and urinary catheter is much easier in infancy. Typically we use a double diaper care where the catheter is brought out through a small hole in the inside diaper to drain into the outer diaper. The inner diaper remains dry and thus prevents rashes and outer diaper is changed whenever it gets wet with urine. In an older child, diapers are very difficult and bulky to use.

      Considering all this, the general consensus of American Academy of Pediatrics is to recommend surgery between the ages of 6 months to one year. At hypospadias foundation and MITR Hospital, we have been operating children around the age of 6-9 months for the last few years with excellent surgical results and happy parents. Once the surgery and the post operative recovery period is over, parents often come and tell us that it was a good decision that they got their kid operated at this early age and now all their worries are over. Some of the parents still worry about getting their kids operated in infancy and come at a later age for surgery. We and the staff can then see the difference in the recovery and post operative issues when compared to younger kids undergoing hypospadias repair. Another way to look at this is that a child with hypospadias will always need surgery, this is a condition which will never get better on its own. The longer we wait, more the parents will think about it and feel anxious. So earlier dealt with, the better it is for everyone. It is definitely better for the kid but it is in a way better for the family and parents as well. And surely it is better for the doctor as his job is to give the best results and post operative comfort.

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        October 10 2012

        Should a distal hypospadias be repaired!!

        Author Dr. A.K.Singal Categories Hypospadias Surgery

        I did not know what was in store for me – there was 6 new patients in clinic and only 4 follow-ups and by the nature of it new patients take more time and follow-ups finish very fast. Anyway, the first patient who walked in was a 3 year old accompanied by young smart looking parents. The boy flashed a big smile and I said hello and he was eager to shake hands. That was a positive sign – Acceptance of me as a friend. Good so far.It was a nice Saturday evening, the watch clicked 7pm and I was in my Pediatric Urology clinic at Vashi with the last 10 urology appointments and was slated to be back home by 8pm.

        Invariably on Saturdays I get late but today I was all energized to finish consultations fast and head back home for a quiet dinner and then catch up on much neglected sleep.

        Then we got down to the business of consultation- the parents had looked up about hypospadias on internet and had found me and then travelled all the way to Navi Mumbai on a Saturday evening for a consultation for their little one who had hypospadias. I examined the eager and cooperative kid- he has a coronal hypospadias with mild tilt of glans (the head of penis). There was no chordee (actual bend of the body of penis) and testes were in normal location. Overall, it looked like a milder distal hypospadias which should be fairly easy to repair with a predictably good result.

        I explained everything about hypospadias – how it happens and how it is repaired and then the QA began. The parents asked – “Is it necessary to repair it? We have heard that it can lead to long term urinary problems and sexual dysfunctions as sometimes the nerves get cut during sensation leading to a numb penis. Also, there are blogs which talk about no need to do surgery in distal hypospadias as there may be long term complications like hair growth, tight passage, fistulas etc.” They had visited an eminent Urologist who had advised against surgery.

        Well, they had done their due research and it was good but sometimes the truth out there may not be whole truth. I had to counsel them and make sure that they know the whole truth while at the same time sounding detached from the whole process. It was after all their kid and their responsibility- my job was to give full, fair and medically sound information and then their job was to make the right decision for their kid.

        So here are the facts as I discussed with them:

        1. As the boy grows and finally the penis size become adult like, the deformity becomes more and more obvious. The glans (penis head) which was tilted will look more and more abnormal.
        2. The prepuce will only be on the top of the head and not on the underside leading to an incomplete prepuce. It looks rather like the head of a cobra in adulthood
        3. The urinary opening will be on the underside of penis and the urine stream will always be downward instead of forward as in a normal child.
        4. The problems as stated above will be more cosmetic than functional but they affect the psyche as he will be able to see that the shape and configuration of his penis is quite different from that of other children. This can lead to deep seated emotional and social withdrawal issues in teenage and adulthood.
        5. Repairs are easier with predictable and better results in childhood. Later on in teenage and adulthood repairs have higher failure rates and pain. Further erections can cause pain and instability in the repaired area after surgery.
        6. The blogs out there contain stories of people who underwent surgery for hypospadias in childhood and now are adults. Thus the care which they received was 20-25 years back. The art & science of Hypospadiology has moved at much faster pace in last two decades and now- the understanding of anatomy of penis & hypospadias is much better, the surgical techniques have evolved and most of the repairs are done in single stage, new instruments for finer surgeries are available, new fine absorbable & non-reactive stitches are available and above all there are doctors who are well trained in managing the children with hypospadias.
        7. Earlier surgeries using skin from scrotum or other body tissues are not done any more so currently any repair causing hair growth in urethra is outdated and not done by surgeons.
        8. Complications like fistula, tight passage (stricture) are less than 5% in experienced, trained surgeons hands for milder distal hypospadias.

        To sum up, it is worthwhile to repair distal hypospadias considering all the above. The science of hypospadias surgery has made sure that the children get the best results for surgery in their early childhood and then live their lives normal without worrying about their reproductive organs.

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