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January 01 2014

Living with Hypospadias- Adults with hypospadias

Author Dr. A.K.Singal Categories Adult hypospadias

The tale of hypospadias does not stop in first few years of life for everyone. This is especially true of adults and adolescents who underwent hypospadias surgery repair using older techniques and with lesser trained Hypospadias surgeons 15-20 years back. While a majority of these have done well, there is a sizable population of adults in India who have persistent issues secondary to hypospadias such as urethral fistulas, persistent penile chordee (bending of penis), urethral stricture or bad cosmetic outcome. As Pediatric urologist and a surgeon with deep interest in hypospadias (hypospadiologist), we keep seeing such patients on a regular basis now.

There are atleast estimated 5 lakh adults/ adolescents in India with untreated, complicated or residual issues of hypospadias in India. Some of these people live an unsatisfied life thinking that no cure is possible because that is what they have been brought up to think. Individuals who have failed multiple surgeries are called Hypospadias cripples in medical community signifying the crippling effect which inadequately treated hypospadias can have in a person’s life.

Fortunately, with newer techniques, better hypospadias surgery instruments, very good sutures like PDS, availability of dedicated hypospadias surgery teams and expert hypospadias surgeons good results are possible in any patient with previous failed hypospadias surgery even in hypospadias cripples.

Here is story in point:

Six months back I saw Mr RK, a 30 year old young man, who had been a case of failed hypospadias – operated for hypospadias twice in his childhood in a hospital in Delhi. Both the surgeries had met with partial success and his parents had left him like that and lost hope at a completely functional urethra. RK had been a good student and went on to do Engineering graduation from IIT and then a MBA from Pune. He had taken up a job in multinational company and now was planning to get married. Infact, he had delayed marriage inspite of a successful career because he was never satisfied with outcome of his hypospadias surgery. That’s why he looked up on internet and came to see us at Hypospadias Foundation in Navi Mumbai.

At the first consultation itself and being in relatively the same age group, we hit it off really well and he was quite frank and objective about his condition and that kind of interaction helps a hypospadias specialist like me. When I examined him, he had a persistent mild chordee but the bigger issue was his urinary opening (meatus) was not on the tip of penis (glans penis) but way down in distal penile location. He had many skin bridges and scarred islands of skin and a large urethral fistula in proximal penile region. There was a bit of penoscrotal transposition as well. On questioning, he was passing 50% of the urine from the urethral fistula and 50% from the distal penile location without any straining and in good urinary stream. None of these problems were major by themselves and could have been cured easily but after two failed hypospadias repairs in childhood, I think parents just gave up hope.

So we discussed with RK at length about the various things which needed to be done-

  • Distal urethroplasty using flap from nearby ventral penile skin,
  • Closure of urethral fistula (fistula repair) in multiple layers with tunica vaginalis flap
  • Correction of penoscrotal transposition
  • And chordee correction by dorsal plication.

The surgery was done next week at MITR Hospital & Hypospadias Foundation. Dr Manish Dubey, Urologist and Co-founder of Hypospadias Foundation helped me with the surgery and management immediately post surgery. RK was sent home the day after surgery. A follow up visit for hypospadias dressing removal was planned on day 5 and catheter removal o day 10.

Some of things especially in adults undergoing hypospadias surgery, which we took care of to ensure smooth recovery and are different from children:

  • Postoperative pain and erections
  • Choosing the right urethral catheter and drainage bag

We were also worried about higher chances of wound infection and bleeding after redo-hypospadias repair. For pain and prevention of erections we gave benzodiazepine derivative tablets and phenobarbitone along with diclofenac and that helped pretty well for two weeks. For the catheter, we used a Foleys silicon catheter for 10 days and left it to drain in a urine bag which RK could carry with him and walk around within his home.

Fortunately, everything went well and now after 3 months of hypospadias surgery, the hypospadias surgery site is healing well and there is no more pain during erections. The urine stream is good and RK is passing from the tip of his penis for the first time in his life standing like a normal man. He is not shy to use the public toilets anymore- He just stands up and delivers.

We have asked him to wait for three more months before planning marriage and these three months he is actually going to spend in finding the right girl for himself. For him, we hope the chapter of HYPOSPADIAS is closed now.

The only question remains whether as a Hypospadiologist I will get invited to his marriage- if yes, how will he introduce me? As the doctor who fixed his penis? I think that is too much and I will just skip attending his marriage and I wish him the best of luck always from our side and from everyone at MITR hospital and Hypospadias Foundation in Navi Mumbai, India.

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    September 09 2012

    Hypospadias in Adults- Setting the right goals and expectations

    Author Dr. A.K.Singal Categories Adult hypospadias

    I get a lot of enquiries about hypospadias through our Hypospadias foundation website – Most of these are from concerned parents, sometimes  from relatives, sometimes from referring doctors but rarely from patients themselves. For writing about themselves, the patients have to be old enough to go on Internet and seek help. And with advancing awareness, these days most of the kids are referred to me in first few months of age and sometimes even in newborn age. So to get an inquiry from a patient happens only a couple of times in a month. And most of these are enquiries before an impending marriage!

    I was intrigued when I got an email from a VK 34 years old man wanting to consult me for hypospadias. My assistant, Akshay, explained to him about my consultation time at MGM vashi and at Mitr hospital.

    On Monday evening, VK wrote to me again saying that he went to MGM Vashi but they refused to make a file for him and sent him back with the explanation that Dr Singal treats only kids till 15 years of age. I felt really bad and I sent an email back to him and asked Akshay to schedule an out of turn consultation for the young man on Tuesday. Tuesday otherwise is usually my free day.

    So Tuesday evening, in walked VK, a smart confident young man. He was working as a senior software analyst in a well known consulting company and was married for last 3 years. The consultation began on a nice note. I went through all the papers dating back to one year of age. VK was born with a scrotal hypospadias and had undergone two stage repair at Wadia Hospital when he was 5 years of age, thereafter he had required a couple of minor procedures for narrowing of passage and urethral fistula but was mostly passing urine well. His main reason for consultation at this time was infertility. Secondary issue which we discussed was splaying of urine at time of passing urine. His urine came out in a form a spray rather than a well directed stream and he would often wet his pants and thus found it difficult to use a urinal for expeditious passing of urine.

    His sperm count was almost normal and he was able to have normal erections and ejaculations. The ejaculate was not forceful so an intrauterine insemination (IUI) had been tried but two sessions had failed.

    His secondary problem of a sprayed kind of urine stream was due to a wide open urinary meatus (hole) with a funnel kind of appearance and lot of loose skin folds around it. Also, the urinary opening was not at the tip of the penis but was rather on the underside about 3 cm from the tip.

    From a functional point of view, the location of the urinary opening was not in too bad a location to cause infertility.  Also, since IUI had failed, I was sure that the infertility problem was not due to hypospadias per se. Given the high incidence of primary infertility these days and advanced age of the mother (34 years), the infertility may have been because of some other factors.

    In his own mind, VK had thought that it was his hypospadias problem which was causing infertility. I spent close to 40 minutes trying to draw diagrams and explaining to him that we should look for other causes of infertility.  Finally, he was convinced and then I referred him to an infertility specialist and an andrologist. The plan was:

    • Re-evaluation of fertility status by checking all the reports of husband and wife again
    • Trial of In-vitro fertilization for having a child
    • And then repair of the hypospadias from urinary point of view once wife if pregnant.

    Both for the patient and the surgeon, it is very important to have the goals and expectations from any treatment set at the beginning of the treatment itself. VK had come to me with a primary issue of infertility and the secondary issue was urinary splaying due to incompletely repaired hypospadias. By solving his hypospadias issue, we could not have solved his infertility problem and I did not want him to have any false hopes and thus get surgery done for the wrong reason/ indication. Overall, VK was very happy with the plan. I hope that he will have a baby soon and then we will fix his rest of the urinary issues in a single stage and well.

    Over the last few years, our team – myself and Dr Manish Dubey have treated about 20 adults with various kinds of hypospadias and residual problems. Some of these have been for urethral fistulas, others for residual chordee or cosmetic issues. Most of these have come just before marriage or when they are facing issues such as VK. A couple of patients actually travelled from south India and one from Dubai to get treated.

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