This lecture will discuss an approach to a child / neonate with Abnormal Urethral opening - Hypospadias & Epispadia:-
Hypospadias
Definition and embryology
Calssifiaction and types
Clinical features
Sequlaes
Age of surgical correction
Treatment
Surgical complications
Epispadias
4. Definition:-
• Hypospadias is caused by failure of development of the tissues
forming the urethra, on the shaft of the penis.
1. The urethral orifice opens on the ventral surface of
the penis and does not reach the end of the glans.
▫ In severe cases, the urinary meatus may open in the scrotum or perineum,
where a disorder of sexual development should be considered.
2. There is deficiency of the ventral foreskin and the skin on the
ventral penile shaft (dorsal hooded foreskin).
3. The lack of tissue on the ventral surface of the penis leads to a
tight bow-string effect, causing a ventral bending of the penis
known as chordee.
▫ This chordee deformity is more marked during erection and will cause
difficulty with intercourse in later life if not corrected.
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9. • The malposition of the urinary orifice and the chordee deformity
are usually present together, but in some cases, severe chordee
may be present with an orifice at the end of the penis.
• Hypospadias affects 1 in 150–200 boys.
• Severe hypospadias with a bifid scrotum and undescended testes
is actually a presentation of a disorder of sexual development
with ambiguous genitalia
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11. The clinical findings in hypospadias are:-
1. Downward deflection of the urinary stream from the
ventrally placed meatus.
2. The penis is bent ventrally with chordee, which causes
difficulty with intercourse.
3. The foreskin forms a dorsal hood and is deficient
ventrally, The dorsal hooded prepuce, which gives
an abnormal appearance to the penis.
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12.
13. Sequelae of hypospadias are:-
1. These disabilities are primarily functional.
▫ the boy may find it difficult to direct his urinary stream,
▫ in later life, intercourse may be difficult if there is significant
chordee.
2. The disabilities are also psychological.
▫ severe anomalies of the penis or a poor cosmetic result following
operative repair may interfere with the development of his
normal male body image.
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14. The age for correction of hypospadias has
been made younger, and now, the
recommended age for repair is 6–12
months.
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15. Associated anomalies with hypospadias :-
• Some increase in other anomalies of the genito-urinary
system:-
▫ 9% incidence of cryptorchidism,
▫ 9% inguinal hernia
▫ 3% renal anomalies
• More severe penoscrotal hypospadias is associated with
a utriculus masculinus, a remnant of the vaginal anlagen
that may predispose to:-
1. recurrent UTI
2. epididymo-orchitis
3. stone formation.
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16. Investigation:-
•Investigation with renal ultrasonography is
recommended.
•Severe hypospadias with bifid scrotum and/or
undescended testes (ambiguous genitalia) requires
full investigation for disorders of sexual
development.
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17. Treatment:-
The four aims of treatment of hypospadias are:
1. To correct the chordee
2. To bring the urinary meatus to the tip of the penis
3. To provide a good cosmetic appearance
4. To achieve the above aims with the minimum
complications
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18. Treatment:-
•Hypospadias surgery is one of the most difficult areas
of surgery in children.
•As the primary defect is failure of tissue
development, there is tissue missing from the ventral
surface of the penis and any simple attempt at closing
the defect has a high failure rate.
• There are over 250 different operations described for
hypospadias, most of which are no longer performed
having been superseded by procedures with better
cosmetic and functional outcomes.
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19. The principles of surgery are as follows:
1. Correct the chordee by releasing the ventral skin that tethers
the penis.
2. Relocate the meatus to the tip of the penis using locally based
skin flaps.
3. Achieve a cosmetic outcome with either a circumcised or
uncircumcised appearance by reconstructing the prepuce.
4. Post-operative urinary drainage is usually aided by a urinary
catheter or a urethral stent.
5. In most cases of hypospadias, surgery is performed in a single
stage; however, in severe cases, the chordee may be corrected
first and then the urethra is repositioned at the tip of the penis
at a later operation to reduce the complication rate.
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20. Post-operative Complications:-
1. Failure of healing with complete breakdown, or a partial
breakdown with urinary fistula formation, is a distressing
problem.
2. Strictures may occur in the neourethra, and poorly corrected
chordee will lead to troubles in adult life.
• These complications used to be common, but the standards of
surgery for hypospadias are now quite high, and one should
expect good results.
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22. •In this condition, the urethra opens at the base of the
penis on its dorsal aspect.
•It is part of the spectrum of lower abdominal wall
defects in which ectopia vesicae (bladder exstrophy) is
a more severe form.
•Most boys with epispadias are incontinent of urine
because the bladder neck is deficient.
•Epispadias as an isolated abnormality in a continent
child is exceptionally rare, even rarer than ectopia
vesicae itself.
•Apart from the problem of the repair of the urethra,
using the same type of urethral reconstruction as in
hypospadias, there are many of the same major
difficulties that arise in ectopia vesicae.
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23. •A newborn baby presents with hypospadias.
Q 4.1 At what age is corrective surgery best performed?
Q 4.2 What are the aims of surgery for hypospadias?
Q 4.3 What are the principles of hypospadias surgery?
• 4.1 6–12 months.
• 4.2 Fix chordee and put urethra on top of glans; satisfactory
cosmetic appearance and minimum complications.
• 4.3 Extensive mobilisation to fix chordee, foreskin advanced to
ventral surface, neourethra constructed, ± post-operative
stenting/urinary diversion, one or two stages.
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