Surgical correction of hypospadias

Published by Bupa's Health Information Team, September 2010.

This factsheet is for parents of boys who are having surgery to treat hypospadias, or people who would like information about it.

Hypospadias affects the development of the urethra in baby boys. It causes the opening of the urethra, through which urine passes, to develop in the wrong place. Surgical correction creates a urethral opening in the correct position and straightens the penis. You will meet the surgeon carrying out your son's operation to discuss his care. It may differ from what is described here as it will be designed to meet your son's individual needs.

About surgical correction of hypospadias

Hypospadias affects the way the urethra develops in baby boys. When the urethra doesn't develop properly, the opening (meatus), through which urine is passed, doesn't come out at the tip of the penis. Instead, it opens at another area of the penis.

Surgical correction aims to create a urethral opening at the tip of your son's penis and straighten his penis to make it look as normal as possible. Surgery is commonly carried out when your son is aged between 10 and 18 months. Alternatively, surgery can be done when your son is around four, shortly before he starts school. In more minor cases, some parents choose to leave the operation until their son is old enough to decide for himself.

If your son has minor hypospadias, treatment can be carried out during one operation. However, with more severe hypospadias, your son may need to have two separate operations. These will usually be done six months apart.

Your son's foreskin will be used to reconstruct his urethra during the procedure, so it's important that he isn't circumcised before the operation.

What are the alternatives?

If your son has minor glanular hypospadias, he may not need any treatment at all. All other types of hypospadias are usually treated using corrective surgery. Your son will be assessed by a paediatric urologist (a doctor who specialises in identifying and treating conditions of the urinary tract in children). He or she will let you know whether your son needs surgery or not.

Preparing for surgical correction of hypospadias

Your son's surgeon will discuss with you what will happen before, during and after his operation, and any pain he might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the operation. This will help you to be informed, so you can give your consent for the operation to go ahead, which you will be asked to do by signing a consent form.

The operation is often done as a day case, but your son may need to stay in hospital overnight so that his progress can be monitored.

Surgery is carried out under general anaesthesia. This means your son will be asleep during the procedure. Your son will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it's important to follow his surgeon's advice.

Before your son's operation, a nurse will:

• ask questions about his general health
  
• check that he hasn't had anything to eat or drink
  
• measure his heart rate and blood pressure

You must tell the nurse if your son has had any allergic or unusual reactions to medicines in the past, or if there is any history of bleeding problems in the family.

What happens during surgical correction of hypospadias?

Surgical correction of hypospadias is usually done during one operation. However, if your son's condition is severe, he may need to have two operations. This might be necessary if there is a severe bend or if there isn't enough skin to make a new urethra. During the first operation, your son's surgeon will use a skin graft from the foreskin to create extra skin for the second operation, which will usually take place six months later.

The operation takes between one and two hours, depending on what needs to be done. The technique used will depend on how much correction is needed.

The operation aims to:

• create a longer urethra so that the urethral opening is at the tip of your son's penis
  
• straighten your son's penis by repairing any chordee (tightening of skin) that is causing his penis to bend
  
• reform the head of your son's penis (glans) into a more normal shape
  
• either create a normal-looking foreskin, if possible, or perform a circumcision
  
• create a normal-looking scrotum

Your son may not need all these different surgical steps; it will depend on how severe his condition is.

What to expect afterwards

Your son will be monitored for a short time after his operation. He may be groggy, and feel or be sick. He will need to rest on his bed or on your lap until the effects of the general anaesthetic have passed.

Your son will have a thin, plastic tube (catheter) fitted which allows urine to drain from his bladder, often just into his nappy, and a large dressing covering his penis. Both of these need to stay in place for a week.

Your nurse will give you advice about caring for your son's dressing before you go home. She may also show you how to put two nappies onto your son, with a hole cut into the inner nappy through which the catheter is passed. This helps keep the dressing dry. You will be given a follow-up appointment one week after the operation so that your son's dressing and catheter can be removed and another follow-up appointment around three months later.

Recovering from surgical correction of hypospadias

Your son will feel some discomfort for a few days after the operation. If needed, you can give him over-the-counter painkillers such as paracetamol or ibuprofen syrup. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice. Don't give aspirin to children under 16.

The catheter can sometimes irritate your son's bladder, causing it to spasm - the muscles in his bladder suddenly tighten and contract. Usually, you will be given anti-spasm medicine for your son before you go home.

It's important to keep your son's dressing as clean and dry as possible. Don't bathe or shower him until his dressing and catheter have been removed. When changing his nappy, use a damp cloth to wipe off any urine or faeces that get on his dressing. It may be helpful to use two nappies to protect the dressing which also act as a cushion against knocks and bumps.

Contact the hospital or your GP if:

• your son complains of severe pain or shows signs that the pain is getting worse; for example, babies and toddlers cry more when they're in pain and are difficult to settle
  
• his wound starts weeping
  
• the amount of urine from his catheter reduces or stops
  
• his dressing falls off
  
• his catheter falls out

What are the risks?

Surgical correction of hypospadias is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side-effects

These are the unwanted but mostly temporary effects after having a procedure; for example, feeling sick as a result of the general anaesthetic.

Common side-effects include pain, swelling and bruising around your son's penis. This usually settles down a few days after his dressing and catheter have been removed.

Complications

This is when problems occur during or after the operation. Most children aren't affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or infection. Your son is likely to need a course of antibiotics for a week after the operation.

Specific complications of surgical correction of hypospadias are rare but can include the following.

• In around one in 15 boys, the original urethral opening reopens so that urine passes through the new and old holes. A further operation is needed to correct this.
  
• Narrowing of the new urethra or its opening - it can become too small for your son to pass urine properly.
  
• Sometimes the repair carried out during the operation can come completely undone, and another operation is necessary to correct it.
  
• As your son's penis grows, it may begin to bend as any remaining chordee becomes more obvious.

There is a higher risk of complications if your son has to have his treatment in two stages instead of one operation.

The exact risks are specific to your son and differ for every person, so we haven't included all the statistics here. Ask your son's surgeon to explain how these risks apply to him.

For answers to frequently asked questions on this topic, see Common questions.

For sources and links to further information, see Resources.