Hypospadias in Adults- Setting the right goals and expectations

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.