Hypospadias Information leaflet for parents Child Health Directorate

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1 Hypospadias Information leaflet for parents Child Health Directorate Please note that this information leaflet is designed to give an overview of the experience that you and your son will go through during his treatment for hypospadias. It is intended to support and inform further discussion and explanation between yourselves and doctors prior to giving consent.

2 What is hypospadias Hypospadias is a condition of the penis that affects 1 in 300 boys. The boys urethra (wee tube) is short. It ends on the underside of the penis, instead of the end of the penis. This results in the boy not being able to wee when stood up. There are different types of hypospadias. Although very minor hypospadias may not require surgery, the vast majority do require surgery. This is usually done shortly after their first birthday. For particular and individual reasons some boys have surgery in later years. However, the intention is for all to have surgery before they start school. Normal Glandular Coronal Subcoronal or distal shaft Mid-shaft Proximal shaft Penoscrotal Scrotal Perineal 2

3 Hypospadias can also be accompanied by Chordee. This causes the penis to curve downwards when erect and may make the penis appear shorter and bent. Chordee is caused by a tight band of fibrous tissue which can pull the penis out of shape. The foreskin in boys with hypospadias is not fully formed. It is very important for him not to have a circumcision before the hypospadias surgery. At the end of the hypospadias surgery most boys would have a circumcised penis. What are the benefits of a hypospadias repair? A hypospadias repair corrects both the Chordee and moves the urethra (wee tube) to the end of the penis so that the boy: Can wee standing up Will have a normal looking penis Will have a straight penis Will have normal sexual function Will not suffer psycho-sexual problems when older What happens when a boy comes to hospital? Please see separate leaflet on your child s admission to hospital for surgery You will be asked to bring in your son the day before surgery One of the plastic surgeons will come to see you and your son He/She may ask you to sign the consent form for the operation He/She will explain to you the procedure and the risks involved Your son will be seen by the anaesthetist. Please see separate information leaflet for general anaesthetic. If your son is aged 1 or 2, please bring in nappies his normal size and nappies one size larger as he may need both sizes after surgery. Request your preference for your son, i.e. cot or bed. One parent may stay by their son s bed side. The hospital provide a bed 3

4 Once you have seen the plastic surgeon, the anaesthetist and the nurse you may be able to go home overnight if you wish and return the following day for surgery. Your nurse will advise you when you need to give your son his last food and drink before surgery. Give your son a bath or shower the evening or the morning before coming to hospital paying particular attention to his penile area. Operation day On the day of the operation you will usually see the consultant or registrar just before the operation. Your son will have a general anaesthetic. Please see parent information leaflet for general anaesthetic. Please note that with anaesthetic and recovery time before and after the operation, it may be as long as 2 ½ hours before your son has recovered enough to return to the ward. After the operation There are 3 main types of operation performed by the consultant for this problem: Bracka I ( the first of a two stage repair if it is not possible to do the hypospadias repair in one stage.) Your son will stay in hospital for 3 days after this operation. The catheter/stent is then removed. He will then be discharged but asked to return to ward 5 or 8, on day 6 after his operation. On return a senior plastic surgeon will then remove some stitches from your son s penis. Bracka II ( the second of the two stage repair.) This happens 6 months after the Bracka I operation. Your son will have to stay in hospital for a week after his operation. He will have his catheter/ stent removed on the 6th day after surgery. There are no stitches to be removed after this operation. Snodgrass Repair. If it is possible to repair your son s hypospadias in one attempt this operation will be done. The postoperative care for this procedure is the same as for the Bracka II repair. 4

5 You will be informed which operation has been done for your son. You will then be aware of how long your son s hospital stay will be. Risks Rarely there are early complications like bleeding or infection that may require further surgery. Occasionally many weeks after hypospadias surgery there may be a urethral fistula (leak of urine from the original opening of the urethra as well as through the new opening at the tip of the penis Urethral stricture (narrowing of the urethra) An excess fold of skin These conditions could be repaired with further surgery that is usually minor Post-operative Care Please see separate leaflet for general anaesthetic. Your son will have a catheter or stent in his urethra (wee tube) A catheter (for boys aged 3 or above) is a fine tube that drains urine from the bladder. A stent (for boys aged below 3) is a finer tube that drains urine from the bladder. If a stent is used, the urine drains from the stent into an outer nappy. The inner nappy covers the operation wound and is only changed when your son has a poo (bowel movement). The catheter/stent is in place to prevent urine from leaking onto your son s wound (Bracka I) or to keep his new urethra from closing up (Bracka II or Snodgrass repair) Your son should not be in too much pain as he is given pain relieving medication. On the ward we use many different types of medicines to keep the children as comfortable as possible: Paracetamol (pain relief) Ibuprofen or diclofenac (pain relief and anti-inflammatory) Dihydrocodeine or morphine (pain relief) Oxybutynin (for bladder spasm) 5

6 Ondansetron (if your son is sick) Co-amoxiclav ( antibiotic to prevent infection which will be given until your sons catheter or stent is removed) Once your son is awake he can have a drink. If he is not feeling sick he can eat as normal, starting with a light diet. It is very important for your son to drink as much as possible. Taking adequate amounts of fluids results in: a good flow of urine through the catheter/stent preventing the catheter/stent from becoming blocked helping to keep the urine clear. Urine may be blood stained for 1 or 2 days after surgery. If your son is sick after the operation, and cannot manage to drink, do not worry. If necessary, additional fluids will be given through a small tube (cannula) into the vein until he stops being sick. This does not usually last longer than the first day. Your son will have a dressing over the operation site on the underside of his penis. For the first two days after your son s surgery he will need to stay on his bed or on a chair to help the surgical wounds to heal. To keep him amused, the nurses or play team can wheel his bed down to the playroom. Sometimes these boys have difficulty post-operatively in opening their bowels. To prevent this potential problem, encourage your son to drink (please bring in his favourite drinks if this helps). Encourage him to eat fresh fruit, weetabix, vegetables and baked beans or drink fresh orange juice. Straining to open his bowels may cause discomfort so it is important to try to avoid constipation if possible. Discharge following Bracka I Your son will usually go home 3 days after his operation once his catheter or stent has been removed and he has passed urine twice. 6

7 He will still have a dressing in place over the graft on the underside of his penis. This will be held in place with stitches. You will be asked to bring your son back to the ward 3 days after going home. This is for removal of the stitches on the underside of his penis. A senior plastic surgeon will also check your son s wound and graft. You will be invited back to the ward one week after your son s first graft check for another review by a senior plastic surgeon. You will be asked to attend clinic with your son 6 weeks after his surgery. After the operation your son s penis will look swollen and odd shaped. It is important to note in boys who have undergone the Bracka I procedure, their urethra will still be either in the same position or drop further back as a result of the chordee release. This appearance is normal for this stage of the procedure and will be improved once he has his Bracka II repair. However, please ask your nurse to check if you are concerned. Discharge Following Bracka II or Snodgrass Procedure Your son will usually go home 6 days after his operation, once his catheter or stent has been removed and he has passed urine twice. Your son will be invited back to the ward for review by a senior plastic surgeon one week later. You will be invited to attend clinic with your son 6 weeks after his surgery. After this operation your son s penis will look circumcised, with a slight scar on the underside This scar will fade as he gets older. For boy s whose parents request that the penis not be circumcised, and there is adequate tissue, the foreskin may be reconstructed. Uncommonly parents may be able to take their son home earlier if a stent/catheter is not necessary, or if they are comfortable looking after the stent/catheter at home. 7

8 Caring for your son following discharge home If you have any problems, contact the ward at anytime on / Do not go to your GP or A and E unless advised. Give your son a quick bath every day once his dressing has been removed. Normal soap or baby bath can be used. If there are any small pieces of dressing remaining on your son, leave them and let them drop off with time. Dress your son in loose underpants, trousers, shorts or nothing at all! If he is still wearing nappies try to avoid using them as much as possible. Fasten them loosely as he will find this more comfortable Your son should not get involved in active games, swimming or cycling until his review in clinic 6 weeks after surgery. Your son should not return to nursery until he has been reviewed on the ward 2 weeks after the operation. Give your son paracetamol if required (unless he is allergic to the drug) as per instructions on the bottle. His wound may be a bit uncomfortable for a day or two. The flow of urine from your son s penis may come out in a spray initially. This may continue until the swelling has reduced. The consultant creates the new urethra when doing the Snodgrass or Bracka II operation. It is important to note in boys who have undergone the Bracka I procedure, their urethra will still be either in the same position or drop further back as a result of the chordee release. This appearance is normal for this stage of the procedure and will be improved once he has had his Bracka II repair. Routine follow up appointments will continue until your son reaches adolescence and this will include psychological support for you and your son if needed. 8

9 Sources of further patient information: Lancashire Teaching Hospitals NHS Foundation Trust is not responsible for the content of external internet sites. July 2009 (Review date July 2012) 9