Penile hypospadias: It is a developmental anomaly characterized by a urethral meatus that opens on the ventral surface of the penis. It affects 1 in 250-300 newborns. The risk of a second child is 10%, and if the father is also affected the risk increases to 25%. It occurs due to an abnormality in the development of the foreskin, glans, urethra and anterior aspect of the penis that results in different anatomical variants. The urethral meatus can be found on the ventral aspect of the penis in any position from the scrotal region to the glans. A certain degree of ventral curvature of the penis, classically known as “Chordee,” is often associated. Without treatment, these patients present a urinary stream directed to the feet that forces them to urinate sitting or with the penis directed upwards,
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- 1 Origin
- 2 Classification
- 3 Causes and risk factors
- 4 Diagnosis
- 5 Treatments
- 6 What should and what should we not do in the newborn with hypospadias?
- 7 What imaging or laboratory studies should we order?
- 8 What associated congenital anomalies should we look for?
- 9 Why should the patient be operated on?
- 10 At what age is it recommended to repair hypospadias?
- 11 What type of anesthesia is required to correct hypospadias?
- 12 What are the most frequent techniques for its repair?
- 13 Sources
In children with hypospadias, the urethra forms abnormally between 8 and 14 weeks of pregnancy. The abnormal opening can be located in any area from the tip of the penis to the scrotum. There are different types of hypospadias, from mild to severe. The type of hypospadias depends on the location of the urethral opening:
- Subcoronal: The opening of the urethra is located somewhere near the head of the penis.
- Penis: The opening of the urethra is located along the stem of the penis.
* Penoscrotal : The opening of the urethra is located in the scrotum. Boys with hypospadias sometimes have a curved penis. For this reason, the way they pass urine can be abnormal and they have to sit down to do it. In certain cases, boys with hypospadias may also have a testicle that did not go down well from the scrotum. If not corrected, they can cause problems later in life, such as difficulty having sex or urinating standing up.
Hypospadiasia is classified by the meatus position.
- Glandular: When the meatus is in the glans.
- Penile hypospadias.
- Distal: in the distal 1/3 of the body of the penis.
- Means: in the middle 1/3 of the penis.
- Proximal: In the proximal 1/3 of the penis.
- Penoscrotal hypospadias: When the meatus is located in the fold between the penis and the scrotum.
- Scrotal hypospadias: When it is in the midline above the median raphe of the scrotum.
- Perineal hypospadias, located in the perineum.
Causes and risk factors
It is caused is that of Barcat which takes into account the position of the meatus once the cord has been resected.
- 70% coronal glanular
- 10% mediopeneana
- 20% perineal scrotal penis
Recently, researchers reported important findings about some factors that affect the risk of having a child with hypospadiasia:
- Age and weight: Moms 35 years of age and older who were considered obese had a higher risk of having a baby with hypospadias.
- Fertility treatments: Women who used assisted reproductive technology to get pregnant were at increased risk of having a baby with hypospadias.
- Certain hormones: Women who took certain hormones shortly before or during pregnancy had a higher risk of having a baby with hypospadias.
They continue to study birth defects, such as hypospadias, and how to prevent them. If you are pregnant or planning it, ask your doctor how you can increase your chance of having a healthy baby.
Hypospadias is usually diagnosed during a physical exam after the baby is born. A routine ultrasound study is not necessary to rule out other associated urological malformations. A differential diagnosis with intersex states must be made in cases of proximal hypospadias with a very small penis and absence of testicular descent. In these cases, a karyotype is performed.
Treatment depends on the type of malformation the child has. In most cases, hypospadias will require corrective surgery. If surgery is needed, it will usually be done when the child is between 3 and 18 months old. In some cases, the surgery is done in stages. Some of the corrections made during surgery include putting the urethral opening in the right place, correcting the curvature of the penis, and repairing the skin around the urethral opening. It may be that the doctor uses the scrotum to make any of the skin corrections, so circumcision is not recommended in boys with hypospadias. The repair first seeks to straighten the penis if there is any bending. Bring the meatus to its normal orthotopic position at the end of the glans. Obtain a conical shape of the glans withvertical meatus that allows a good flow of urine and with skin repair looking for a result as similar as possible to the appearance of a circumcised boy.
What should and should not be done in the neonate with hypospadias?
First of all, circumcision should not be practiced for any reason since the foreskin will be used to form the missing urethra (neourethra). If the newborn is a carrier of an intersexual state, it is considered an emergency and its immediate study should be started to assign it the corresponding sex. It is important that the child’s first consultation occurs during the first postnatal weeks to dispel any doubts.
What imaging or laboratory studies should we order?
All patients with hypospadias should be asked for an ultrasound of the urinary tract, in order to rule out associated congenital malformations. the voiding cystogram is indicated in patients with penile-scrotal, perineal hypospadias or a history of urinary tract infection or family members with urological abnormalities. Oral cytology (bar body search) or karyotype will be requested in patients with intersex.
What associated congenital anomalies should we look for?
The most frequent are: inguinal and cryptorchid hernia, which occur in 10-25% of patients with hypospadias. Other less frequent are: single kidney, horseshoe kidney, double collecting system, however the incidence of significant abnormalities that require surgical intervention is less than 3%, which is slightly higher than the normal population.
Why should the patient be operated on?
- They have an inability to urinate standing up.
- They present significant ventral curvature which prevents a correct future sexual relationship.
- They have an incomplete erection.
- In adult stage they present dyspareunia.
- The psychological damage caused by the dysfunctions described is prevented.
At what age is it recommended to repair hypospadias?
The optimal age seems to be between 6 and 15 months, which is what most experts currently recommend. If hypospadias is diagnosed at birth, it is suggested to undergo surgery at 6 months of age. It is important to note that hypospadias must be fully repaired by the time the child enters school.
What type of anesthesia is required to correct hypospadias?
In most patients, a caudal block is placed (regional anesthesia), thus avoiding general anesthesia and the risk it entails. With this procedure, continuous analgesia can be administered.
What are the most frequent techniques for its repair?
There are more than 300 surgical techniques for its repair, which shows that none is 100% effective. The techniques are usually divided into one or several surgical times techniques.
- Techniques of a single surgical time (Very well accepted at present): Snodgrass, * Mathieu, Flip flap, Mapgi.
- Urethral advancement, Duckett (vascularized flap).
- Multi-time techniques (Not well accepted today)
- Durham Smith, Crawford Technique.