International Patients
+916262690790

Author Archives: Dr. A.K.Singal

HomeHypospadias Foundation   Articles by: Dr. A.K.Singal
February 02 2024

Hypospadias and undescended testis: Diagnosis, surgery and treatment plan

Author Dr. A.K.Singal Categories Hypospadias

Hypospadias and undescended testis (also called cryptorchidism) are both very common clinical problems in young children. While hypospadias occurs in 1/150 boys, undescended testis is even more common. But the treatment for both of them is different.

Undescended testis: What is the usual treatment plan?

When we see a newborn child with undescended testis, we often wait before advising surgery as nearly 60% of the testis which are undescended at birth may come down to a normal scrotal location by 6 months of age. This is even more true if the testis has already come out of the tummy and can be felt by the doctor during the examination in the OPD (palpable undescended testis). For the testis which are higher up in abdomen (intra-abdominal undescended testis) chances of coming down spontaneously are quite less but possible.

Hypospadias: What is the usual treatment?

Hypospadias on the other side, almost always requires surgical correction. And the right age for doing the hypospadias surgery is between 6-18 months of age. We typically advise the hypospadias repair surgery to be scheduled around 9-10 months of age. For hypospadias without chordee, it is usually a single stage surgery while for severe hypospadias or severe chordee, we choose to do a two-stage hypospadias repair procedure.

Both hypospadias and undescended testis occurring together- what does it mean?

When both hypospadias and undescended testis occur together, the diagnosis and treatment is much more complex. The most important thing to be done for these children is to investigate them for disorder of sex development or DSD. DSD is present in upto 15% of children who have both hypospadias and undescended testis. If the hypospadias is severe like scrotal or perineal hypospadias and the child has both sided undescended testis, the chances of a DSD condition go upto 50%.

So, what tests we do when we see a child with both hypospadias and undescended testis?

Any child who has hypospadias and undescended testis, should be investigated for a disorder of sex development. We are worried about conditions like mixed gonadal dysgenesis or true hermaphroditism or even severe variety of congenital adrenal hyperplasia.

Typical tests to rule out such conditions include:

  1. Ultrasonogram to check for any abnormal organs inside, status of gonads.
  2. Karyotype – to check for chromosomal abnormalities.
  3. Hormonal evaluation – Genitogram or cystoscopy: some of these children if they have DSD also may have remnants of vagina or utricular diverticulum which can be seen only on a genitogram or a cystoscopy. MRI scan: may be needed in selected cases to rule out hemiuterus or fallopian tube.

Treatment plan for hypospadias and undescended testis

As outlined above, the first thing to do is to find out if the child has a DSD. If there is DSD, then we involve a pediatric endocrinologist and then consider assigning the gender and surgical plan starts from there.

If there is no DSD, then we prefer to do the hypospadias repair and undescended testis surgery together at around 9-10 months of age. If the undescended testis is palpable, it can be brought down in one stage via a short open surgery. If the testis is intra-abdominal then child will need a laparoscopic single or staged orchiopexy. For hypospadias, if there is no chordee or mild chordee, then we can do the orchiopexy and single stage hypospadias repair together. If hypospadias is very severe or there is severe chordee then we would need to plan for a two-stage hypospadias repair.

Summary: If your child has hypospadias and undescended testis, you must visit a qualified pediatric urologist and a hypospadias specialist. Before any surgery, a full evaluation has to be done as it has repercussions for future sexual function and fertility. But the good thing is that hypospadias and undescended testis repairs can be combined to help child get good result from both in one hospital stay whenever possible.

At Hypospadias Foundation India, we have treated thousands of children with hypospadias and some of them also had a undescended testis. A thorough evaluation and a plan for management for both was given and it worked very well for these children. Dr A.K.Singal and Dr Ashwitha Shenoy are rated as the best hypospadias surgeons in India. If you need an opinion or consult us for your child, please do write to us at hypospadiasfoundationindia@gmail.com or fill up this contact form.

Keywords: undescended testis, cryptorchidism, hypospadias surgery, hypospadias and undescended testis, right age for hypospadias surgery, right age for undescended testis surgery, undescended testis surgery, disorder of sex development, surgery for DSD, hypospadias repair, hypospadias specialist, best hypospadias surgeon in india, hypospadias treatment in india

January 01 2024

Does Hypospadias cause male infertility?

Author Dr. A.K.Singal Categories Cases worth noting

For some men with hypospadias, a congenital condition where the urethral opening lies somewhere on the underside of the penis, questions about fertility can loom large. While hypospadias itself doesn't directly impact sperm production, its associated complications can sometimes pose challenges. But remember, this doesn't mean that all men with hypospadias will necessarily be infertile. Let's delve into the link between hypospadias and fertility, exploring potential concerns, available solutions, and fostering hope for
fatherhood.

Understanding Hypospadias:

During fetal development, normally the urethra forms by folding of tissues from scrotum to the base of penis to the tip of penis. The failure of this urethral closure leads to hypospadias. The severity of hypospadias varies, with the opening appearing anywhere from the scrotum (scrotal hypospadias) to base of penis (penoscrotal hypospadias) to near the tip of penis (distal hypospadias). Besides the misplaced opening, most of men with hypospadias also have a downward bending of penis during erection- called chordee. 5% of hypospadias may also have associated undescended or an absent testis which can lead to lower sperm production. Such men need to be investigated for a disorder of sex development (DSD) or intersex.

Hypospadias and Fertility: the Possible Connections:

In isolated hypospadias with both normal testes, the sperm production usually remains unaffected, yet certain hypospadias-related factors can influence fertility:
 Urethral location: In severe unrepaired hypospadias cases such as scrotal or perineal or penoscrotal hypospadias, ejaculation might not be able to reach the vaginal introitus, hindering fertilization.
 Penile curvature: Significant curvature can make intercourse physically difficult. Sometimes erection can also be painful when there is significant chordee
 Meatal stenosis: abnormal hypospadias opening may be very small leading to urinary and sperm flow obstruction.
 Prostatic utricular diverticulum: Some men with severe hypospadias may also have a large sac near their prostate gland where sperm tubes (vas deferens) open. In such cases sperms may not flow out easily for fertilisation.
 Post hypospadias surgery issues: At Hypospadias foundation, we see lot of men who have had repairs done earlier and have poor fertility though they have a normal sperm production. The common reasons for this are complications of hypospadias surgery such as: residual curvature or chordee, stricture in new passage, diverticulum or baggy new urethra or fistulae in the urethra.

 Psychological considerations: Emotional concerns about body image or sexual function can sometimes affect intimacy and overall fertility.

Hypospadias Treatment Options: Paving the Way for having children

Fortunately, advancements in hypospadias surgery and infertility treatment offer effective solutions for addressing hypospadias-related fertility concerns:
 Hypospadias repair surgery: This procedure reconstructs the urethra and corrects penile curvature, often restoring normal ejaculation and improving sexual function. If there are complications from previous hypospadias surgeries such as stricture, residual chordee, fistula or a diverticulum- these can be repaired by an expert hypospadias surgeon leading to cure for infertility.
 Assisted reproductive technologies (ART): In cases where natural conception proves challenging, sperm retrieval techniques like testicular biopsy or micro epididymal sperm aspiration (MESA) can be combined with IUI, IVF, or ICSI to achieve pregnancy.

Maintaining Hope: Fatherhood is Within Reach for people with Hypospadias:

Do consult an expert and best hypospadias surgeon first. The hypospadias surgeon will check and confirm that the hypospadias repair is proper and there is no structural issue in repair. If there is some residual issue in hypospadias surgery, then that needs to be corrected first. If the infertility persists, then you must visit an andrologist for assisted reproductive techniques.

It’s crucial to remember:
 The majority of men with hypospadias have normal fertility.
 Early surgical intervention significantly improves the chances of successful fatherhood.
 Advanced treatments like ART offer alternative paths to parenthood. Open communication with your hypospadias doctor is key to understanding your unique
situation and exploring suitable fertility options. Remember, hypospadias does not define your potential as a father. With proper support and available treatments, you can navigate this journey and realize your dreams of having babies and building a family. At Hypospadias foundation, we treat hundreds of children and adults with hypospadias every year. Since 2008, Dr A.K.Singal, rated as the best pediatric urologist and hypospadias surgeon in India and the world, has devoted his life to helping people with hypospadias get best results and normal life. Along with Dr Ashwitha Shenoy, pediatric surgeon and hypospadias surgeon and a partner at Hypospadias foundation, the team at Hypospadias foundation, has deep expertise in diagnosing and treating complex hypospadias.

References:

 American Urological
Association: https://university.auanet.org/core/pediatric/hypospadias/index.cfm
 National Institutes of Health: https://www.ncbi.nlm.nih.gov/books/NBK482122/
 Mayo Clinic: https://www.mayoclinic.org/diseases-
conditions/hypospadias/diagnosis-treatment/drc-20355153

If you wish to have a teleconsult or a second opinion from Dr Singal/ Dr Shenoy, please write to us hypospadiasfoundationindia@gmail.com or fill up this contact form: https://www.hypospadiasfoundation.com/contact/

November 11 2023

Guide to choose the best hypospadias surgeon for your child

Author Dr. A.K.Singal Categories Hypospadias

Hypospadias is a common congenital anomaly diagnosed at birth. Most of the children will need repair surgery for hypospadias and this surgery should be done by 18 months of age in a child who is born full term and is otherwise healthy. The hypospadias surgery, when done, should be carried out by an expert hypospadias surgeon. The hypospadias surgeon should be trained in hypospadias surgeries and have extensive experience and dedication to hypospadias-related work. 

As a parent of a child with hypospadias, you may be confused about how to choose the best hypospadias surgeon. Any pediatric urologist or pediatric surgeon can operate on a child with hypospadias, but every surgeon may not get the desired and best post-surgery results. Here are a few tips that will help you shortlist the best hypospadias surgeon for your child.

  1. Ask your pediatrician: Pediatricians and pediatric urologists or surgeons often know each other well and work closely. Pediatricians are the first doctors to diagnose hypospadias and they can guide you to an experienced hypospadias surgeon who does lot of such surgeries and has good results for hypospadias surgery. Pediatricians often also get to see the children post-surgery and hence know the outcomes for each surgeon. Ask your pediatrician to guide you to seek the best hypospadias surgeon for your child. 
  2. Connect with parents of children with hypospadias: A parent of a child with hypospadias goes through a great deal of experience when it comes to hypospadias surgery. From pre-surgery OPD visits to post-surgery care, they become experts on how to manage their child in the hospital and after surgery. New parents can discuss with other parents whose child has already completed hypospadias repair and get an honest opinion regarding the hypospadias surgeon, experience in the hospital, and their overall experience. This will help other parents gain confidence and decide what’s best for their child.
  3. Search online for the best centres of expertise for Hypospadias Surgery: Most of the good centres for hypospadias treatment have a comprehensive website and a knowledge centre. Key things to look online are- qualification of the hypospadias doctor, years of experience, kind of cases they have managed, their success stories, their online reviews, the surgery videos, their publications and whether they are so good that they are training other surgeons. In the best hypospadias centres, their website will have enough information on all these points.
  4. Visit your hypospadias surgeon in the OPD: Make sure you visit your hypospadias surgeon or connect with them online for a hypospadias consultation at least once before you plan the surgery. In the Outpatient department (OPD) of a hypospadias surgeon you will find many other children with hypospadias which indicates hypospadias surgery is performed regularly at that hospital. Ask your hypospadias surgeon about the cases done so far, the success rate and similar cases done in the past which will help you gain confidence in the surgeon and take a decision if he/she is the right surgeon for your child.
  5. Success rate of hypospadias repair surgery: Every surgery has its own set of complications but when it comes to hypospadias the complication rates vary widely at various centers. The best hypospadias surgeon should have a success rate of more than 90% with a complication rate of under 10%.  When you visit your hypospadias surgeon do ask them about the success rate of surgery at their center. 
  6. Expertise in managing complex hypospadias: Complex hypospadias such as perineal, scrotal hypospadias and redo hypospadias (hypospadias after multiple previous failed attempts) need to be managed very differently. If your child has such a hypospadias, make sure that you ask your hypospadias surgeon about their experience in managing such cases and the technique which is going to be done in your child so that you are prepared for the post-surgery period. An experienced hypospadias surgeon will be well versed in managing complex cases as well as primary ones. 

The first surgery is the best chance for a complete cure from hypospadias. Once the first surgery fails, subsequent surgeries become difficult. Hence, it is important that you do full research and choose wisely. Choosing the right hypospadias surgeon is not an easy decision for any parent. Every parent wants the best surgeon for their child. 

At hypospadias foundation, we treat more than 200 children and adults every year with hypospadias. Our dedication and expertise in hypospadias makes us one of the leading centers for hypospadias repair in the world. Do not hesitate to write to us or visit us for more information on our expert hypospadias surgeons. We will be happy to offer a second opinion or help you with understanding hypospadias treatment for your child or yourself (adult hypospadias)

Contact Form for Hypospadias Foundation

Please fill all clinical details and upload pictures and clinical summaries (if available)

    Attach Documents (pdf | jpeg | mp4)
    (upload size upto 5mb)

    October 10 2023

    Typical worries in parents of boys with hypospadias

    Author Dr. A.K.Singal Categories Hypospadias

    Hypospadias though common is still unknown to the general population. When a parent finds out that their child has a genital abnormality(hypospadias) they get very worried thinking of the child’s future. Due to limited resources which are available in the online platform, parents do not get a clear idea when it comes to hypospadias. This blog is directed to parents who have children with hypospadias, to ease their concern and improve the knowledge surrounding hypospadias.

    1. Is surgery needed for Hypospadias? Surgery is required in hypospadias to correct the chordee, to create a urinary passage and bring the opening to the tip of the penis. The repair can be staged or single stage depending on the degree of chordee (downward bent of the penis) and severity of hypospadias. The risk of complications following surgery at our centre is less than 5%. The most common complications which we encounter are wound infection, fistula formation, diverticulum formation and meatal stenosis. An additional surgery may be required in some of these complications. Following hypospadias surgery, the cosmetic result will be similar to a circumcised penis. The meatus will be at the tip on the glans and the child would be able to pass urine in a single straight stream.
    2. Anaesthesia during hypospadias surgery: Hypospadias surgeries are done under general anaesthesia. It is important that besides a pediatric urologist, a pediatric anesthesiologist doctor is available to give anesthesia safely to children. Right from dosage of medications to managing airway is very different in children when compared to adults. Hence, at Hypospadias Foundation we have 3 skilled pediatric anesthesia experts who give anesthesia for hypospadias surgery. In addition to general anaesthesia the anaesthetist will also give an injection in the lower spine (caudal anaesthesia) which gives good pain relief to children for 12 hours after the surgery. Pain relief is our priority after surgery so that children can be comfortable after surgery and don’t remember hospitalisation as a painful episode. Besides caudal anaesthesia(during the surgery), we provide adequate pain relief with analgesics for a few days post-surgery.
    3. Pain after hypospadias surgery: Besides common surgical pain, which is easily manageable with pain killer medicines, two main reasons why children can develop pain in the post operative period are either due to bladder spasms or erections. Bladder spasms are controlled by a tablet oxybutynin which is started after the surgery and is continued till the catheter removal. Erection in the penis mainly occurs during early morning hours but can occur anytime in the day. Mostly the pain which occurs during erection is also managed well by the painkillers. The pain decreases significantly once the dressing and catheter are removed. However, penis continues to be sensitive for 2-3 weeks after the hypospadias repair surgery.
    4. Infertility in hypospadias:  Hypospadias can cause male infertility due to various reasons. They may be due to abnormal location of the meatus, presence of chordee and low semen count. The altered opening of the urethra can cause problems in ejaculation, hence causing infertility. Presence of chordee can make sexual intercourse difficult or painful. Presence of an associated undescended testis may be associated with a low sperm count. We need to understand that not all men with hypospadias will have fertility problems. The severity of hypospadias and the success of surgical repair will ultimately decide if they will be able to father a child. Hence in men with hypospadias suffering from infertility they need to get in touch with a hypospadias surgeon because getting the hypospadias repaired will increase their chances of having children.  
    5. Risk of hypospadias in future generation: The risk of hypospadias in future generations is influenced by a number of factors such as genetic and environmental factors. Some studies suggest that the risk of hypospadias may be increasing. The prevalence of hypospadias in the United states has increased by 10% from 1970 and 2000 as per the study published in the journal Nature in 2011. Hypospadias is a condition that can be inherited from the parents. If the father has hypospadias, then the risk of developing hypospadias in future generations will be 5-10%. Similarly, if first child has hypospadias, the risk in second boy is almost 5%. 
    6. Cost of surgery and insurance coverage/cashless/mediclaim: Hypospadias being a penis birth defect is classified as an external birth defect which can be easily diagnosed as soon as the baby is born. Hence, if parents take an insurance policy after the baby is born, hypospadias surgery treatment costs as cashless Mediclaim are not covered by most of the insurance companies in India atleast while in USA, UK it is covered under insurance benefits. The situation is different for some of the corporate insurance group policy holders. Some big corporates issue very employee friendly mediclaim policies which cover all medical and surgical treatments for the employees and their families. Such mediclaim policies may cover all pre-existing as well as birth defects for their employees and hence hypospadias repair procedure may be covered by the insurance companies in these circumstances.

    At Hypospadias foundation, we see almost 500 children and adults with hypospadias every year. The counselling in clinic, before surgery and after surgery focussing on making the families and patients comfortable, increasing their knowledge, and solving their queries. While there may be information available with pediatricians or on google, it is always better to consult a specialist hypospadias surgeon to have genuine answers to all the questions. 

    Contact Form for Hypospadias Foundation

    Please fill all clinical details and upload pictures and clinical summaries (if available)

      Attach Documents (pdf | jpeg | mp4)
      (upload size upto 5mb)

      1 2 3 4 … 17