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Hypospadias Program

When a child is diagnosed with a medical condition, many parents feel overwhelmed with questions. Whether your child has been recently diagnosed with hypospadias, will soon be undergoing corrective surgery for the defect or needs further treatment due to complications from a procedure performed at another hospital, it is important to know as much as possible as your family makes important decisions about the child’s care.

At the CHOC Children’s Urology Center, we are proud to be leaders in the diagnosis, treatment and long-term follow-up care of patients with hypospadias. With complication rates below the national average, our team of pediatric urology specialists partner with patients and their families to develop the very best treatment options based on each child’s unique health conditions.

While there are many urology specialists at hospitals across the country, it is important that children, especially those with hypospadias, work with a pediatric urologist right from the start. Our fellowship-trained pediatric urologists understand a child’s medical needs both now and in the future. They are gifted at not only treating hypospadias patients when they are diagnosed as newborns, but are also well-known for working with children who have had unsuccessful hypospadias treatments.

The Basics of Hypospadias

Dr. Gordon McLorie, pediatric urologist, tells us about hypospadias, a condition with no known cause that affects children.

Frequently Asked Questions about Hypospadias

Hypospadias is a condition that affects the urethra and the foreskin on a male’s penis. The urethra is the tube that carries urine from the bladder to the outside of the body. Hypospadias is a disorder in which the male urethral opening is not located at the tip of the penis. Most commonly with hypospadias, the opening is located along the underside of the penis close to the tip, but can be located anywhere along the urethra all the way down into the scrotum.
The cause of hypospadias is still unknown. Hypospadias is a condition that is present at birth and is the result of incomplete development of the urethra. Commonly seen with hypospadias is incomplete development of the foreskin. This typically is noted with extra foreskin on the top side of the penis and no foreskin on the underside of the penis. This incomplete development of the foreskin may also be referred to as “hooded foreskin.”
According to studies:

• Hypospadias does have a genetic component, and sons of men with hypospadias do have a higher risk of having it as well.
• Prematurity and low birth weight are also considered risk factors for hypospadias.
The following are the most common signs of hypospadias.

• Abnormal appearance of foreskin and penis on exam.
• Abnormal direction of urine stream.
• The end of the penis may be curved downward (chordee).

The signs of a hypospadias may resemble other conditions or medical problems. Through careful examination, the CHOC Children’s Urology Center specialists rule out other conditions before making the hypospadias diagnosis.
A health care professional usually diagnoses hypospadias at birth and can be identified with a physical examination. It is important to not circumcise a child with suspected hypospadias until he has been seen by a pediatric urology health provider. Learn more about making an appointment with a CHOC Children’s Urology Center pediatric urology specialist.
Mild forms of hypospadias may not require any intervention. If a hypospadias is more severe, surgical correction may be recommended. If left unrepaired, the following complications may occur as the child grows and matures:

• The urine stream may be abnormal. The stream may point in the direction of the opening or it may spread out and spray in multiple directions. It may also cause the stream to shoot directly downwards, towards the boy’s feet or body.
• The penis may curve as your baby grows causing sexual dysfunction later in life, resulting in a condition called chordee.
• If the urethral opening is close to the scrotum or perineum, the child may have problems with fertility later in life.

Specific treatment for hypospadias will be determined by your baby's health provider based on:

• The child's gestational age, overall health and medical history.
• The extent of the condition.
• The baby's tolerance for specific medications, procedures or therapies.
• Expectations for the course of the condition.
• The family’s opinion or preference.

Not all hypospadias defects will need to be repaired, which will be determined with the child’s health provider and family. If the hypospadias needs surgical repair, it is usually done when the baby is between 6 and 24 months, when penile growth is minimal. At birth, the child should not be able to undergo circumcision, as the extra foreskin may be needed for the surgical repair. The surgical repair can usually be done on an outpatient basis (and may require multiple surgeries depending on the severity).
At the CHOC Children’s Urology Center, we follow our patients throughout childhood by checking their urine flow rates and post urination residual measurements to ensure that the urine is flowing and emptying the body as it should. Although rare, strictures or fistulas can develop after the hypospadias repair has been made. These are either “leaks” where a second hole develops along the site repaired (fistula) or an area within the urethra that scars and tightens causing a stricture. Signs that a stricture has developed include urinary tract infections, straining to urinate or feeling like one has to push or grunt to urinate.

Postoperative Care for Hypospadias and Chordee

These instructions are general guidelines and specific changes or instructions for each patient may differ. Please follow instructions given by the child’s surgeon and CHOC Children’s Urology Center staff.

Hypospadias is a condition in which the male urethral opening is not located at the tip of the penis. Chordee is a birth defect frequently associated hypospadias. This information is intended for patients who will be undergoing surgery to correct hypospadias and/or chordee by one of the CHOC Children’s Urology Center specialists at our hospital. The procedure is often considered an “outpatient” surgery in which the child arrives in the morning and leaves the same day. If the child will need to stay in the hospital overnight, the family be made aware of this before the surgery.

Before the Procedure

Please buy over-the-counter antibiotic ointment (i.e. Bacitracin, Neosporin, Polysporin) and ibuprofen, which can be generic or a name brand such as Advil or Motrin. The ibuprofen should be appropriate for your child’s age—infant, child or adult formula.

Diet

After surgery, start with clear liquids then progress to a regular diet as tolerated. The anesthesia can cause some stomach discomfort (nausea or vomiting) and a fever 24 to 48 hours after the surgery.

Antibiotics

The patient may be given prophylactic antibiotics after the surgery to prevent urinary tract infections. Generally the patient takes the antibiotics for sevent to ten days or until the stent (tube) is removed (if there is a stent present). Please use the antibiotics until the patients is told to stop by our office.

Pain Management

Some children may be sent home with Tylenol #3 to be taken as needed for pain. Most children need it for one to three days. If the doctor prescribed Tylenol #3 (with codeine) tablet or elixir, please try to give it to the patient as little as possible. Codeine causes constipation and can be very painful for the child. Should the child become constipated, we recommend using an over-the-counter stool softener, like Miralax, for relief and to try using ibuprofen instead of the Tylenol #3. Do not take Tylenol #3 and regular Tylenol (also known as acetaminophen in its generic form) at the same time. Taking too much Tylenol (acetaminophen) can cause a harmful overdose. If needed, ibuprofen and ONE Tylenol product can be taken within the same time period.

Also, put crushed ice into a sandwich bag (Ziploc-style bags help prevent leakage) and place this in between the double diapers, or put over underwear to help reduce swelling and pain. Never apply ice directly to the skin.

Dressing Instructions

Patients may be sent home with a stent (small tube) in the urethra, which is held in place with a stitch. It is normal to have a small amount of bleeding and/or clear to yellowish oozing. Sometimes some red/pink colored urine comes out of the stent, and this is normal. The bandage is removed at the child’s first visit after surgery. If the bandage falls off on its own, start applying antibacterial ointment to the surgical site several times per day. If stool gets on the bandage, do your best to clean it off with a baby wipe. If the bandage is covered in stool, please call the on-call doctor and ask if it is alright to remove the bandage early. Call (714) 509-3919 and the answering service will give you directions for the on-call doctor.

Bathing Instructions

The child’s surgeon will provide instructions on when the child may bathe after surgery. At times it is acceptable to bathe with the stent in, and other times it is not. Usually, if the child has a stent in place, we ask the surgical area is not submerged in water and to do sponge baths instead. During the healing process, or about one to two weeks after surgery, bathe three to four times daily in plain water (no soap) for 15 minutes and air dry, once instructed that it is alright to begin bathing. The over the counter antibiotic ointment (not cream) should be applied at each diaper change, or four times each day for one week. If antibiotic ointment is unavailable, Vaseline may also be used.

Preventing Adhesions

When the healing skin sticks together, that is called an adhesion. Once the bandage is off, or you are able to see the coronal groove, you can start to help your child avoid creating adhesions. At each diaper change, or four to six times each day, make sure the shaft (body) skin of the penis is not healing to the glans (head) of the penis. Gently pull the shaft skin down towards the body so that you can see the coronal groove go all the way around the penis. The frenulum will be the only area that should attach the glans of the penis to the shaft. Apply antibacterial ointment to the coronal groove to help lubricate the area and prevent “sticking.”

Stent and Dressing Removal

Patients will be given an appointment to return to the office to have the bandage and stent removed. After it is removed, keep bathing him as noted above. You can start tapering the baths down to three per day and then two per day, etc.

Activity Restrictions

For two to three weeks after the surgery the child should avoid trauma to the surgical area—no rough housing, contact sports, bicycle riding or physical education. Younger children should avoid walkers or straddle toys (such as bouncy chairs or rocking horses). At the follow-up appointment (about one week after surgery), our specialists will provide specific information as to when it is safe to return to activities.

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CHOC Children's is affiliated with the UC Irvine School of Medicine