by Robert Steele, MD (see more from this expert)

Q

We had a micro-preemie (25 weeks - 1 lb 7.4 oz) and are very fortunate that he is doing very well. What we need information on is hypospadias. What is the anticipated surgery and recovery times? Is there anything we need to look out for or be aware of post-surgery? I know this depends on the severity (our son is not severe, I believe a grade 2), but what is the likelihood of multiple surgeries?



A

As you know, the normal position for the opening of the penis is located at about the center of the tip of the head (or glans). Hypospadias is when the opening of the penis is located below the end of the penis. It may be just below the tip of the penis or down as far as the scrotum. Hypospadias occurs somewhere in the neighborhood of 1 in every 300 male births, and fortunately, about 90% are of the minor variety. In other words, the vast majority have the opening just under the center of the head or just below the ridge of the head of the penis.

The male genitalia has its basic structure developed by about the tenth week of pregnancy. Then, the penis begins to grow and the tube that allows the urine out begins to close. This is completed by the 14th week of pregnancy. Hypospadias occurs when the closure of this tube (called the urethra) causes the end to present itself below where it's supposed to be. How and why this happens is not known exactly. However, it is felt to involve a combination of hormones as well as perhaps genetic factors.

Hypospadias can sometimes be associated with inguinal hernias and undescended testicles. However, it does not seem to be associated with any abnormalities with the bladder or kidneys. Because of this, it is usually not necessary for a lot of testing to be done prior to corrective surgery.

The decision about whether to surgically correct the hypospadias depends upon a couple of factors:

  1. Does the penis also have a tether which prevents full erection? Occasionally, the penis may have a bend in it (called a chordee) that causes an abnormal erection. This requires correction to allow for adequate sexual function.
  2. Will the opening eventually allow for the child to stand when urinating? This ability has important psychological consequences later in childhood.

Once the conclusion is made that surgical correction is necessary, the next decision is when it should be done. Initially, correction was done once the child turned 18-24 months. However, with the advances in the safety of anesthesia as well in the knowledge of psychological stress the older child endures with the surgery and recovery, it is clear that the optimum time for repair is within the first year of life. Therefore, most pediatric urologists suggest repairing the hypospadias when the child is between 6-12 months to reduce separation anxiety.

Congratulations on your new addition to the family! And I am certainly happy to hear that he has done so well after being born so early. There are a number of techniques that the pediatric urologist uses to correct the hypospadias depending upon how far down the opening is and whether there is a chordee or torsion (twisting) of the penis. But in general, the penis is first straightened (if needed) by loosening or removing the tissues. Then, the tube through which the urine travels (the urethra) is lengthened often by using the skin from the foreskin to create a longer tube. A catheter is placed for a short time and then removed prior to going home. Almost all repairs of mild hypospadias are able to be done with just one operation often as an outpatient. It is now typical for a child to have the repair and go home the same day or first thing the next morning. The two most common complications after surgery are narrowing of the opening called stricture and a leakage point which develops during healing called a fistula. You can expect the urologist to examine the penis carefully upon follow-up for these two problems which, if they occur, are generally easily treatable.