In the last few years, we have been treating a lot of adults coming with unrepaired primary hypospadias wanting to get hypospadias repair surgery done. Adult Hypospadias repair surgery is a very different ballgame from child hypospadias surgery. Traditionally clinical outcomes for adult hypospadias surgery have not been as good with pediatric hypospadias surgeries as:

1. Chances of infection are high
2. Due to erections at night, chances of dehiscence are high

After having done hundreds of adult hypospadias surgeries, we can clearly see differences in adult hypospadias and children with hypospadias. Whether it is the size of penis, overall anatomy of tissues, pre-surgery preparation, intra-operative instruments and stitches or post-op care- everything is very different. Over the years, we have understood various steps which should be done to decrease risk of hypospadias surgery complications in adults. This has led to improved results in adult hypospadias surgeries.

Our Stepwise Adult Hypospadias Surgery and Care protocol:

1.Pre- surgery counselling: We make sure that expectations are set right. While hypospadias surgery can correct the curvature, cosmetic appearance and urine flow issues, hypospadias surgery cannot increase the size of penis or improve fertility. In our hypospadias clinic, after we have examined the adult hypospadias patients, we discuss what they want and the propose the outlined treatment plan.

2. Pre-surgery tests: Before hypospadias surgery is planned, we like to do blood tests for ruling our diabetes, check out any risks for anesthesia or any infection. We also like to do a urine routine test to check for any infection. Chest Xray and ECG test are done to make sure that the person is fit for anesthesia. We also take a consult from a physician to make sure that the
person is fit to undergo anesthesia for hypospadias surgery.

3. Pre-surgery preparation: We start a betadine scrub bath for cleaning pubic area twice daily 2 days before surgery. Pubic hairs are not shaved as shaving 1-2 days before surgery can lead to higher risk of infections. Typically, we trim the hair in the OT with a hair trimmer.

4. Surgery: General anesthesia with epidural block is given. All aseptic precautions are taken to prevent infection. Special microsurgery adult hypospadias instruments are used. Sutures used are also absorbable ones. Care is taken to handle tissues, nerves and blood vessels very gently. Dressing is done to support the penis and catheters are secured properly. Once the patient is out of anesthesia, we shift out to recovery room and thenward.

5. Post-Surgery care: We give IV antibiotics for 2 days and also open the dressing on day 5 to check for any infection. For some cases, we also advise hyperbaric oxygen therapy for 5-7 days. Catheter in adult urethroplasty is kept for a longer period as healing is slow. We typically keep two catheters – a suprapubic catheter and a urethral catheter. Both are kept for 3 weeks.

6. Follow-up: After urethral catheter removal, we typically clamp the suprapubic catheter and once the patient is passing urine from urethral well, we remove the suprapubic catheter after 2 days.

By following this protocol, our results in adult primary hypospadias surgeries have become the best in India and amongst the top centres in the world. Our success rates in Adult Hypospadias Surgery are over 95% in primary one or two stage repair with very less number of people needing further surgeries. At Hypospadias Foundation, a dedicated team of surgeons takes care of adult hypospadias. Dr A.K.Singal is a reputed and top hypospadias surgeon who has been doing hypospadias repair surgeries since 2006 and is rated amongst the best in the world for clinical results. Dr Ashwith Shenoy is a hypospadias surgeon who has deep experience in managing hypospadias. Both of them work closely giving best outcomes to adults with hypospadias. Given their team work and dedication to success rates in hypospadias, it is no surprise that people come from all over India and more than 20 countries to seek hypospadias treatment under their care.

What can adult hypospadias surgery accomplish:

1.Straight penis by chordee correction: If the person has a hypospadias with a bent penis, it can be fully corrected, and a straight penis can be achieved. We use a variety of chordee correction techniques like 16 dot plication Chordee correction surgery in an adult redo hypospadias using 16 dot plication in adults to achieve good outcomes.

2.Achieve urine opening at the tip: In almost all primary hypospadias, we are able to achieve an urinary opening on the tip of penis. In failed hypospadias or ones with previous surgeries (unless the glans -the head of penis- is damaged), with modern techniques, we are able to achieve opening on the tip. Rarely, if there is fibrosis or deformed glans due to previous surgery- we try to bring the opening as close to the head as possible.

3.Good Cosmetic result: In most of adult hypospadias, we are able to achieve a good cosmetic result with a straight penis, opening on the tip and a circumcised appearance. With modern stitches, good instruments and trained expert hypospadias surgeons, the stitch marks are also very less. Single stage hypospadias repair in an adult

4.Ease in intercourse: Some of the adults come to us with difficulty in intercourse due to chordee. Once chordee is corrected, the intercourse becomes painless and easy.

5.Standing up and passing urine: One of the chief complaints in hypospadias is that the urine goes backwards. Hence, the male has to sit to pass urine. This is especially true for proximal penile, penoscrotal or scrotal hypospadias. Once hypospadias is corrected, the urine goes forwards and the person can stand up and pass urine like a normal man. (urine stream pic)

6.Straight stream without spraying: Most of unoperated or failed hypospadias repair come to us with spraying of urine. This happens when the urine hole is not on the head, the urine doesn’t get a proper direction to form a nice stream. Once the hypospadias is corrected, urine starts coming in a normal single stream from the head of the penis and directed forwards without spraying.

7.Passage of urine from one hole: Some of the failed hypospadias cases may have multiple holes due to urethral fistulae. Due to these the person may be passing in 2, 3 or more streams. We have seen cases where the person was passing urine like a watering can due to multiple holes. This can all be corrected with successful adult hypospadias surgery by an expert surgeon.

8.Healthy mental state: We have seen lot of young adults, who feel inferior and incomplete due to a deformed penis because of hypospadias. They often are hesitant to establish relations with opposite gender. Once repaired with a good result, these men report higher mental self esteem and comfort in establishing healthy relationships. If the depression and anxiety is severe, it is a good idea to discuss with your surgeon and take some psychology help before and after surgery,

What adult hypospadias surgery cannot accomplish:

1.Increase in penis size: Hypospadias surgery leads to correction of anomaly but not an actual increase in size of penis. In some cases with severe chordee, unrepaired penis may look small due to chordee. Once we correct such cases, the penis may look longer due to straightening of the penis.

2.Solve premature ejaculation: Premature ejaculation is not related to the hypospadias and hence surgery can’t solve this. For such issues we refer the cases to adult urologist for treatment.

3.Erectile dysfunction: Some men with hypospadias come with erectile dysfunction, generally this is not related to hypospadias itself. It may be psychological or due to some other anomaly. Hypospadias by itself doesn’t cause erectile dysfunction and repairing hypospadias doesn’t improve it either. For such issues we refer the cases to adult urologist for treatment.

4.Cure infertility: Hypospadias may cause difficulty in intercourse if there is severe chordee but generally doesn’t cause infertility. Hence, if the sperm count is low or poor, doing a surgery will not solve this. For such issues we refer the cases to adult urologist for treatment.

It is important that adults with hypospadias discuss these issues threadbare with their treating hypospadias surgeon before surgery. We also take help of a clinical psychologist or an adult urologist whenever needed before surgery to set the right expectations. At Hypospadias Foundation India, we are dedicated to helping adults and children with hypospadias get the right diagnosis, full counselling, expectation setting and surgical treatment with empathy. With both the surgeon and the patient aligned, great outcomes and happiness can be achieved.

Dr A.K. Singal is rated as the best hypospadias surgeon in the world for adult hypospadias surgery. Dr Ashwitha Shenoy is a well-trained pediatric urologist and hypospadias surgeon working with Dr Singal. Together as a team both of them treat hundreds of adults and children with hypospadias from across India and the world every year with best care and results. With advancing experiences, the complications of adult hypospadias have decreased significantly, and success rates are above 96% at Hypospadias Foundation.

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. Hypospadias cause male infertility in certain cases due to these complications. 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 the penis to the tip of the 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 the base of the penis (penoscrotal hypospadias) to near the tip of the penis (distal hypospadias). Besides the misplaced opening, most men with hypospadias also have a downward bending of the penis during erection – called chordee. Hypospadias can cause male infertility as 5% of cases may also have an associated undescended or 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, and you suspect hypospadias cause male infertility, 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/

Watch Buccal Mucosa Graft Urethroplasty Video here:

Watch Two staged Buccal Mucosa repair surgery in a child:

Hypospadias is the most common urological birth defect occurring in upto 1/150 newborn boys, which measures upto almost 100,000 (1 Lakh) new cases every year. While most of the cases are not hereditary or genetic, 6-8% of hypospadias cases have family history of hypospadias or associated genetic disorders. In the current era and in cities, most of these children are referred to pediatric urologists or surgeons in early childhood and receive timely treatment for hypospadias. This was not true 20 years back or even now in many parts of the world. Hence, there are a large number of adults living with hypospadias across the world either unrepaired or some who have failed hypospadias surgery in childhood. In India alone, there are an estimated 5 lakh adults who have either not received hypospadias surgery or have failed hypospadias surgery in their earlier years and their families or they themselves have given up.

Every year, we receive adults from many countries in South East Asia and rest of the world who travel to India to Hypospadias Foundation to find treatment for their Hypospadias problem. Recently, a young man travelled from Nepal for hypospadias treatment. We would like to share the story.

Reaching Hypospadias Foundation:

Mr N.S. was born with hypospadias and was diagnosed soon after birth. Due to lack of knowledge and pediatric urology/ hypospadias specialists in Nepal, his parents could not get him treated for hypospadias in childhood. He grew up to be a smart boy and completed his graduation and got employed with an infrastructure company in Nepal. But somewhere at the back of his mind he had this nagging doubt about treatment of his hypospadias issue. He kept on searching whether he can get treatment with good results for hypospadias at the age of 23 years but no one gave him a satisfactory answer. Finally he contacted Hypospadias Foundation at Navi Mumbai, India- a team of hypospadias surgeons led by Dr A.K.Singal and Dr Manish Dubey. He sent his medical records by email and also some pictures. After an electronic opinion, he finally travelled to Navi Mumbai in September 2014.

Examination:

Mr N.S. was examined by Dr A.K.Singal, Pediatric urologist and expert Hypospadias surgeon in Hypospadias Clinic at Hypospadias Foundation, Navi Mumbai, India. He was found to have distal penile hypospadias with mild chordee. No previous surgery had been done. The midline raphe of the penis was misaligned to one side causing a slight bend in the penis also to one side called penile torsion. N.S. was counselled for surgery as well post-op recovery and underwent distal penile hypospadias repair surgery (urethroplasty) the next day.

Hypospadias Repair surgery:

Since it was a case of primary hypospadias and there was no previous surgery done, the urethral plate was still preserved well. We planned to do a single stage TIP repair (Tubularised Incised plate urethroplasty or Snodgrass repair). The new urinary tube (urethra) was made over 12 Fr silicon catheter and covered with two additional layers for secure healing and prevent fistula. First layer was with corpus spongiosum called spongioplasty and second was with dartos from foreskin on the top of penis. Finally excess foreskin on top was excised imparting a circumcised look to the penis. N.S. was discharged the day after surgery on antibiotics, analgesics (painkillers), antacids and antispasmodics. Additionally a medicine was given to decrease erections temporarily. One week later, we removed the dressing in clinic and finally the catheter was removed on day 10. N.S. had some pain initially on passing urine but within 2-3 days he was passing urine normally from the tip of penis. There was an issue with delayed healing of skin on underside of his penis which finally healed completely in 2 months. He has been passing urine normally and came to see us at 6 months follow-up after surgery this week (18^th March 2015) and was extremely happy with the result of hypospadias repair surgery. He has healed well with a single stage surgery and does not require any further surgery. He is planning to start seeing girls now and get married soon. We have given him a clearance to go ahead with marriage and send him our best wishes from Hypospadias Foundation.