Penile Surgery. For evenings and weekends, the UM Health System (UMHS) Operator will connect you to one of our urology resident physicians on-call.

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1 When should I call after surgery? Call anytime if: severe pain lasting more than 2 days. temperature higher than F (38.5 C). bleeding that soaks diapers like menstrual pads. no urine in diapers for more than 3-4 hours. For non-urgent questions, we recommend calling the Urology Call Center during business hours (M-F between 8 am and 430 pm) to speak to one of our nurses rather than calling the operators at night. Our nurse clinicians are specifically qualified to help you with any of your questions and concerns, and your calls will be returned within a day in most cases. For evenings and weekends, the UM Health System (UMHS) Operator will connect you to one of our urology resident physicians on-call. What should I expect after surgery? 1. It is not unusual for children to experience burning with urination after penile surgeries, especially hypospadias repair. If your child goes home after the hypospadias repair without a catheter, he may experience burning pain with urination for up to 3-4 days. This is normal. 2. Continuous pain from surgical incisions declines gradually over the course of 3 days. The use of regional blocks (performed at the time of surgery; see the section on regional blocks) can provide an effective numbing over the surgical area for several hours after the surgery when the pain might be the greatest. The use of oral pain medications, (734)

2 especially during the first 24 hours, will also minimize the pain. (See the section on post-op medications.) 3. A small smudge of blood in the diaper (not soaking like menstrual pads) is normal, especially during the first 2-3 days. 4. The penis will look bruised, discolored (especially at the head part), and swollen during the first 2 weeks. These are not necessarily the signs of infection or internal bleeding. If the child is without significant pain after 2 days, the urine drains well, and fevers do not occur, then the penile appearance of swelling and bruising is likely normal. 5. If the child is sent home with a catheter, then he might have occasional bladder spasms, caused by the catheter irritation inside the bladder. Unlike the continuous pain from surgical incisions, bladder spasms occur intermittently, lasting for few minutes. Older children will describe bladder spasms as severe urgency to urinate and/or lower abdominal cramps. For children sent home with a catheter, an oral bladder spasm medication will be prescribed. What are regional blocks? Regional blocks are procedures performed by either anesthesiologists or surgeons at the time of surgery to numb up the area of the surgery (similar to dentists making your mouth numb while working on root canals and fillings). They are done while the child is completely asleep, and they will not feel any needle pokes. Although the children are asleep during the surgery, the use of regional blocks can help reduce the need for other anesthetic and pain medications that might cause side effects such as prolonged drowsiness and nausea. What are the options for treatment? For penile surgeries, such as hypospadias and chordee repair, the following options are available: - 2 -

3 Penile block. Penile blocks are suitable for simple penile surgeries such as circumcision and meatoplasty. Local anesthetic is injected near the area of the penile nerves, providing numbing of the penis for several hours. It does not affect the child s ability to urinate. For more complex surgeries like hypospadias, penile blocks may not provide a complete numbing. Caudal block. Caudal blocks are similar to an epidural that pregnant moms receive during delivery. Instead of lower back, however, it is a one shot numbing medication injection near the tailbone area (where he sits). If successful, caudal blocks provide more complete numbing for complex penile surgeries such as hypospadias and chordee repairs. The medicine is injected into the area just outside of the spinal fluid. The actual spinal cord is at the area near the lower back, and the caudal block needle poke is not anywhere near the actual spinal cord itself. For several hours after the caudal block, older children should not be allowed to walk around, since their legs might be weak and wobbly. Caudal blocks are generally suitable for young children under the age of 4-5, and on occasions, it may not be suitable if the tailbone area is not well developed or evenly shaped. Spinal block. Spinal blocks are procedures where a needle puncture is made into the area where the spinal cord and spinal fluid are located in the lower back. The actual medicines injected can vary, and they typically include either a numbing agent, a narcotic pain medication, or a combination of both. It can provide up to 24 hours of pain relief. We recommend spinal blocks for older children who cannot receive caudal blocks and those who will be admitted to the hospital after the surgery for further observation. Rarely, it can lead to headaches afterward due to spinal fluid leak at the needle puncture site. You will be able to discuss the regional block options more in detail on the day of surgery with the surgical and anesthesia teams. You can also ask questions - 3 -

4 about them during your pre-operative visit to the Procedure Readiness Center (PRC). Although you do not need to decide beforehand, it is helpful for you to be aware of these options. An effective regional block is extremely useful for helping children to be comfortable after the surgery, especially during the first day when the pain might be the greatest. What are the postoperative medications? 1. Pain medication. Your child will be sent home with a prescription strength pain medication called Lortab (hydrocodone-acetaminophen elixir). The actual dose will be specified on the prescription according to your child s age and weight. We recommend giving the child the first dose 3 hours after you leave the hospital and then repeat every 6 hours for the first 24 hours (total of 4 consecutive doses), even in the middle of the night. It is important to give the first dose before the numbing effect of the regional block wears off. During the first day, regular dosing of pain medication, rather than waiting until he is in pain, will make the child s recovery smoother. Starting on the second day, you may use the same dose of medication every 6 hours as needed if he looks uncomfortable. After 3 days, you may also use either regular Tylenol or Motrin as needed. For children who are allergic to Lortab, they might be sent home instead with Codeine. 2. Bladder spasm medication. If the child is sent home with a catheter, then he will receive an age and weight appropriate dose of Ditropan (oxybutynin). The actual dose for your child will be specified on the prescription. The bladder spasms are intermittent, lasting for few minutes, and therefore, Ditropan should be given 3 times a day continuously until the catheter is removed. Some of the side effects include constipation, dry mouth, facial flushing, and irritability. 3. Antibiotics. If the child is sent home with a catheter, he will receive a preventive daily dose of antibiotics. We generally use Bactrim or - 4 -

5 Septra (they are the same; trimethoprim-sulfamethoxazole). The actual dose for your child will be specified on the prescription. The antibiotics should be given once a day until the catheter is removed. If the child is allergic to sulfa (contained in Bactrim or Septra ), then he might be sent home instead on either Keflex (cephalexin), amoxicillin, or furadantin. 4. Antibiotic ointment. It is important to apply a generous amount of antibiotic ointment (such as Bacitracin or Triple antibiotic ointment) all over the penis, especially at the tip. The ointment should be applied at least 3 times a day and/or with every diaper change. Cover the head of penis like you are frosting a cupcake. While the bandage is still on, focus on the exposed head of the penis. Once the bandage is off (see the section on Penile Bandage), include the neck area of the penis where you see sutures. 5. Stool softener. Children can develop constipation after any surgeries because of anesthetics and medications. If he does not have a bowel movement 1 day after the surgery, give him an appropriate dose of overthe-counter stool softener/laxative, such as Colace or Milk of Magnesia, 2 times a day until bowel movement happens. If no bowel movement occurs after 2 days (even with stool softener and laxative), call our office. Disclaimer: This document is for informational purposes only and is not intended to take the place of the care and attention of your personal physician or other professional medical services. Talk with your doctor if you have Questions about individual health concerns or specific treatment options The Regents of the University of Michigan Author: Julian Wan, MD Last Revised December