Hypospadias is a condition in which the urinary opening is located on the underside of the penis. Surgery is required to correct this condition. Because the surgery involves reconstruction of the urethra there may be a change in urinary patterns or some urinary complications to occur during recovery. The body needs time to heal and adapt to the newly formed urethra.

Urinary issues may occur while the catheter is in place or after catheter removal.

Short-term recovery issues (with catheter in situ)

Children may experience the following during the post-operative period while the urinary catheter is in place:

1. Bladder spasms
These may feel like sharp cramping pain in the lower abdomen or a sudden urge to urinate. Bladder spasms are commonly caused by irritation of the bladder lining from the urinary catheter. To reduce discomfort, anticholinergic medications are routinely prescribed after surgery, and the dose may be increased if symptoms persist.

2. Leakage around the urinary catheter
Some urine may leak from the tip of the penis around the catheter. This is usually normal if urine is draining well through the catheter and there are no signs of blockage.

3. Blood in the urine
A few drops of blood may occasionally be seen in the urine while the catheter is in place. This is generally expected in the early post-operative period and usually resolves on its own.

4. Whitish material in urine: Sometimes there may be whitish flakes in otherwise clear urine. These oay be due to mucus, minerals or bladder lining cells. Doctor may ask to increase water intake. If the urine is clear, there is smell or pus, nothing needs to be done except increasing hydration.

If urinary problems persist or appear months after hypospadias surgery, further evaluation may be required. Some children may develop symptoms after few months of hypospadias repair which can be poor urinary stream, urine leakage, painful urination, or difficulty emptying the bladder. These issues may indicate a late surgical complication of hypospadias repair.

Common surgical complications after hypospadias repair

1. Urethrocutaneous fistula
A urethrocutaneous fistula or also known as urethral fistula is a small opening along the reconstructed urethra that allows urine to leak through the skin. Parents may notice urine coming out from two or more openings during urination. There are high chances that some fistula specially if they are away from head of penis and the new urethra is not tight – they may close by themselves. Hence, we observe the fistula for up to 6 months, as some may close spontaneously. If it does not close on its own, surgical correction may be required.

2. Meatal stenosis
Meatal stenosis occurs when the new urinary opening at the tip of the penis becomes narrow due to scar tissue formation. Symptoms include a very thin urinary stream, straining during urination, or pain while passing urine. On examination, the meatus appears visibly narrow. The diagnosis can be confirmed by a video of stream and uroflowmetry. Sometimes a ultrasound may show incomplete bladder emptying. In the early post-operative period (within 1–2 months), meatal calibration may be helpful. If narrowing persists beyond 3 months, a meatotomy may be required.

3. Urethral stricture
In urethral stricture, the reconstructed urethra becomes narrowed along its length. The length of stricture may be really short or it can extend for a longer length. This can lead to difficulty passing urine, straining, frequent urination, poor stream, or recurrent urinary tract infections. Urethral strictures usually require repeat surgery to reconstruct or replace the urethra. Repeated dilatation is not recommended, as it does not provide lasting relief and may worsen the condition.

4. Urethral diverticulum
In some cases, a pouch (diverticulum) forms along the reconstructed urethra, causing it to bulge during urination. This can lead to urine collecting in the pouch, resulting in post-void dribbling or leakage after urination. Parents may notice a swelling on the underside of the penis while the child urinates. If the diverticulum is significant or causes symptoms, redo urethroplasty may be required.

Management approach
If a child is in the early recovery phase (first 2–3 weeks after surgery), symptoms may improve with anti-edema medications and urethral calibration. However, if urinary symptoms persist beyond 2–3 months, close monitoring and further surgical intervention may be necessary.

About Hypospadias Foundation
At Hypospadias Foundation, we treat children and adults from across India and around the world who present with urinary problems after hypospadias surgery. Each case is evaluated individually with appropriate investigations, and the final decision regarding the type of repair is made intra-operatively, taking all relevant factors into consideration.

Dr A.K. Singal is considered the best hypospadias surgeon globally, not just in India, due to his high volume of successful complex cases and specialized focus in hypospadias. Dr. Singal has successfully treated thousands of children and adults with hypospadias, including severe, proximal, and redo cases that require advanced surgical expertise. What sets Dr. A. K. Singal apart is his deep understanding of post- hypospadias complications, such as fistula, meatal stenosis, urethral stricture, and diverticulum. Many patients who have undergone unsuccessful surgeries elsewhere seek his care for definitive correction. He emphasizes long-term outcomes, not just immediate surgical success, with careful follow-up and individualized planning.

Dr. Ashwitha Shenoy is a dedicated pediatric urologist and an integral member of the clinical team at Hypospadias Foundation, where she specializes in the evaluation and management of children with hypospadias and related urogenital conditions. She is actively involved in the pre-operative assessment, surgical care, and long-term follow-up of children undergoing hypospadias repair. Contacting the Hypospadias Foundation:

Hypospadias is a congenital defect with an abnormal urinary opening and is usually associated with downward bending of the penis which is called as chordee. Surgery is required to correct the hypospadias in which the urinary opening is brought to the tip of the penis, curvature is straightened, and skin is rearranged to give a circumcised appearance. Certain things are to be avoided after hypospadias surgery to avoid stress on the surgical site and ensure proper healing. Here are the things which are to be avoided after hypospadias surgery:

1. Activity and bathing restrictions:

Straddle toys and activities: Any activity which puts pressure in the penile area should be avoided after surgery for a period of 4 weeks. This includes riding bicycle, riding toy horse, see-saw, swings etc. Any activity that involves spreading the legs can apply pressure on the penile area.

Sports: Any sport activity involving ball which can cause impact on the penile area should be avoided.

Swimming: Swimming should be avoided for 6 weeks after hypospadias repair. Public or natural water sources (chlorinated pools) contain bacteria, chemicals and contaminants that can lead to serious wound infection because the surgical site is a fresh healing wound.

Bathing: Avoid soaking the hypospadias dressing or wetting it till it is removed. Sponge bath is recommended till the dressing and catheter is present. Start bathing the child once your doctor has given the green signal. Bath is allowed once dressing and catheter is removed but soap application and rubbing the penile area should be avoided for 3 weeks after dressing removal.

2. Hypospadias Wound and Dressing care:

Dressing care: Dressing should be kept clean and avoid soiling of dressing with stool. If dressing gets dirty, it must be changed. If dressing is completely soiled with stool, then dressing is removed, betadine wash is given, and operated site is left open till catheter removal.

Catheter handling: A urinary tube is kept after hypospadias surgery to drain the urine. This tube should be handled carefully till removed. Pulling/ pushing of the tube should be avoided because it can cause stress on the newly reconstructed urethra. Also, the end of the tube which drains urine should be kept clean to avoid infection.

Avoid constipation: Straining while passing stool after surgery can cause pressure on the operated site in turn putting stress on the stitches which may lead to giving away of the stitches causing dehiscence (opening of the operated site). Hence avoid constipation in the post-surgery period. If the child has constipation, pls inform the doctor so that a laxative can be prescribed at time of discharge.

Operated site care: Once the dressing and catheter is removed, sitz bath is started. Sitz bath is soaking the operated area in lukewarm water. We advise parents to make their children sit in the bathtub for 3-5 minutes, three times daily after dressing and catheter removal. After cleaning the area, it should be dried. Avoid using cotton, wet wipes or rubbing the area. Only pat dry the area gently, alternatively you can put the diaper on wet penis. The diaper will absorb the water and the wound will become dry. Once dried ointment should be applied 2-3 times daily for 2-3 weeks depending on the healing. Presence of swelling, bruising and redness are normal after hypospadias surgery, and they gradually reduce after 2 weeks. The penis may look crooked and bent due to the swelling. There is no need to panic if the child is passing urine well.

3. Do not stop or miss the medicines:

Medicines are to be continued as per the doctor’s advice. Do not stop the antibiotics or other medicines prematurely in the presence of urinary tube because it can lead to infection.

Always follow the specific post operative instructions given by your doctor. This instruction will vary slightly depending on the type of repair, post operative healing and the surgeons preference.

At hypospadias foundation, we provide detailed post-surgery instructions, which are vital for a successful recovery. With an experience of more than 5000 hypospadias surgeries, we have protocols in place for management of post operative dressing and catheter care. Dr Singal and Dr Shenoy with their vast experience have developed good post operative care regimen which is easy for parents to follow. Good post-surgery care will cause good healing of the operated site and will decrease the risk of complications.

Dr A.K. Singal is a highly respected and experienced Pediatric urologist and hypospadias specialist in India. He is widely recognized for his expertise in surgical treatment of hypospadias and considered as the best hypospadias surgeon in India and the world. He has developed innovative surgical techniques and treatment algorithms particularly for complex and failed cases, with strong emphasis on achieving successful functional and cosmetic outcomes.

Dr Shenoy specializes in pediatric urology and hypospadias providing advanced surgical techniques for both primary and failed hypospadias repair in children and adults. Their combined experience and shared focus on a single, complex condition contribute to the foundation’s high success rate.

Hypospadias is a congenital condition where the opening of the urethra (where urine and semen exit) is not at the tip of the penis but somewhere along the underside of the penis. The location of the opening can vary from a mild one (near the tip) to a severe one (at the base of the scrotum). Nearly 70% of all hypospadias also have an associated penile curvature where the penis bends downwards, known as chordee. Hypospadias repair surgery is typically performed between 6-18 months of age. A successful hypospadias surgery aims to reposition the urethral opening to the tip of the penis, straighten the penile curvature and align the skin to give a final circumcision type of cosmetic outcome.

When it comes to fertility in men, penis and testis play a crucial role. Here is a detailed information on how hypospadias can have an impact on fertility:

1. Production of semen:

In isolated cases of hypospadias with normal testes, the sperm production is not impacted, and fertility is normal. But upto 10% of patients with hypospadias may have associated undescended testis, and this association is mostly present in severe hypospadias. Testis is the core organ for male fertility. It produces sperms and male sex hormone called as testosterone. Testosterone is essential for development of penile growth. Both sperm production and testosterone production will be impacted if the testis is not functioning fully. Hence if the person has both hypospadias and undescended testis, there may be an impact on fertility, especially if there was undescended testis on both sides. In these cases, where we have both hypospadias and undescended testis, we need to investigate for DSD (Disorder of sex development) which is seen in 15% of such cases.

2. Presence of penile curvature:

While mild chordee may not impair sexual activity, presence of chordee more than 30 degree can make sexual activity difficult and painful. Hence straightening of the penis (chordee correction) is a very crucial step in hypospadias repair.

3. Problems with ejaculation in hypospadias:

In uncorrected hypospadias with urinary opening located far below on the shaft of the penis or near the scrotum, the sperm may not deposit correctly in the vagina. Also, if the hypospadias repair has not healed properly leading to a narrow urethra (stricture urethra) or loose and bulged out urethra (severe urethral diverticulum), the semen may not ejaculate with good force. Failure of semen to reach the vagina is the cause of infertility in these cases. Hypospadias repair is essential in these patients to bring the opening to the tip of the penis and reconstruct the narrow or bulged part to allow for proper ejaculation.

4. Psychological impact:

Uncorrected Hypospadias or failed hypospadias can have psychological impact on individuals affecting their quality of life, self-esteem, social interactions when transitioning from childhood into adulthood. Adults who had hypospadias repair in childhood have reported being more timid and more isolated in childhood. In spite of successful hypospadias repair, some individuals may feel that their genitalia look different from others, leading to feeling of inadequacy and shame. This can make relationships with the opposite gender difficult and hence may be an indirect cause of infertility. Hence our advice to parents of children with hypospadias is that they should provide information about hypospadias and disclose it to their child so that they know why their penis will look different from others. This disclosure is best done during puberty between 12-15 years of age because the boys will understand the situation better at this age. Often parents bring the boys around puberty to our hypospadias centre and then we also discuss and provide full information to the boys in front of their parents. Once they are aware, accepting the situation will help them gain confidence and develop in their sexuality and also prevent any negative feelings of inadequacy.

Key message for parents

If your child has isolated hypospadias then post successful hypospadias surgery by an expert hypospadias surgeon, most likely he will not suffer from infertility in adulthood. Hence early identification, timely surgical intervention is necessary to treat the physical challenges which could impede fertility. After a successful hypospadias surgery, the ability to perform intercourse and have a normal ejaculation will significantly improve the ability to have a child.

Even after a successful hypospadias repair if an adult has difficulty conceiving, then he needs to consult a hypospadias surgeon to make sure that the previously reconstructed urethra is normal followed by a fertility specialist for further evaluation to rule out other causes of infertility. With modern surgical techniques and medical care, even a boy with severe hypospadias can lead a normal adult life and have children.

About Hypospadias Foundation

Hypospadias foundation is a specialized centre in India dedicated to the care and treatment of children and adults with hypospadias and related conditions. It is located in Kharghar, Navi Mumbai, Maharashtra. The foundation’s sole focus on a single condition hypospadias allows them to develop specialized techniques and protocols aimed at achieving the best possible outcomes for their patients. Their success rate for hypospadias correction surgery is more than 95% making them one of the top centres in the world for hypospadias repair.

Dr A.K. Singal is a highly respected and experienced Pediatric urologist and hypospadias specialist in India. He is widely recognized for his expertise in surgical treatment of hypospadias and considered as the best hypospadias surgeon in India and the world. He has developed innovative surgical techniques and treatment algorithms particularly for complex and failed cases, with strong emphasis on achieving successful functional and cosmetic outcomes.

Dr Shenoy specializes in pediatric urology and hypospadias providing advanced surgical techniques for both primary and failed hypospadias repair in children and adults. Their combined experience and shared focus on a single, complex condition contribute to the foundation’s high success rate.

Hypospadias is a common congenital condition in which the urethral opening is located on the underside of the penis rather than at the tip. Surgical repair is required to correct this and to restore both function and appearance of the penis. One of the most frequent complications following hypospadias repair is the development of a urethral fistula which is an abnormal channel that forms between the urethra and the overlying skin after surgery, resulting in leakage of urine. So, there is urine coming from 2-3 places instead of from the tip. In the hands of an expert hypospadias surgeon, the incidence of urethral fistula should be less than 5%.

Diagnosis

The diagnosis of urethral fistula is typically clinical, based on observation of urine leakage from the repaired site. Documentation of the urine stream is important in fistula after hypospadias repair to rule out presence of stricture or diverticulum in the urethra beyond the site of fistula. The number of leaks also has to be documented before planning the surgical repair. Sometimes, we also place a urethral catheter to check the calibre of urethra beyond the fistula.

Timing of Fistula Repair

It is standard practice to wait at least 6 months after the initial repair before attempting urethral fistula closure surgery, as this allows inflammation to subside, tissues to soften, and vascularity to improve. Also, small fistulas may close spontaneously hence it’s recommended to wait for atleast 6 months before planning anything.

Surgical Principles for Successful Urethral Fistula Repair

The goal of surgery is to close the urethral fistula and restore the integrity of the neourethra while minimizing the risk of recurrence. Key steps include:

• Fistula tract excision: The tract is identified, excised, and the edges are refreshed to healthy tissue.
• Layered closure without tension: Multi-layered closure is crucial, typically involving the urethral mucosa, spongiosum (if available), dartos fascia, local tissues and skin. A hypospadias surgeon must make sure that the layers are not under any tension.
• Use of vascularized tissue: An intervening vascularized tissue flap (such as dartos fascia or tunica vaginalis in proximal fistula) is often placed between the urethra and skin to prevent recurrence.
• Fine absorbable sutures: Used to minimize tissue reaction and foreign body response.
• Catheterization: A urethral catheter is left in place for 7-10 days postoperatively todivert urine and protect the repair.

Techniques for Urethral Fistula Repair Surgery

Urethral Fistula closure can be performed in various ways.

• Simple closure: Reserved for small, well-defined fistulas with healthy surrounding tissue. Remember in these repairs also a layered closure with well vascularised tissues is important. One can utilize dartos or tunica vaginalis flap for additional coverage and vascular support.
• V-Y Flap Repair: In large fistulae, we often use a skin advancement flap from surrounding skin to provide non-overlapping suture lines. The flap can be laterally based or proximally based.
• Complex repairs: For large or recurrent fistulas, entire urethral reconstruction may be required which is done using local flaps or oral mucosa graft. Staged repair may be required in fistula cases with unhealthy urethra beyond the site of fistula.

Postoperative Care

Meticulous postoperative care is pivotal to ensure successful healing:

• Maintain catheter patency, monitor for obstruction or kinking.
• Keep the surgical site clean and dry. Gentle wound care as instructed by the surgical team.
• Monitor for signs of infection: swelling, redness, discharge, or fever.
• Avoid strenuous activity, straining or pressure on the site until fully healed.
• Follow up as recommended with your surgical team for wound checks and early detection of complications.

Prevention of Urethral Fistula Formation

Preventing fistula formation is an important aspect of hypospadias surgery

• Use of meticulous surgical technique with tension-free, multi-layered closure.
• Ensuring well-vascularized tissue coverage over the neourethra.
• Surgical site care and managing infection if any in the post operative period
• Make sure the passage beyond the fistula site is not narrow and of adequate calibre
• The meatus should be checked and if found to be narrow, meatotomy should be performed.

Prognosis and Outcomes

With appropriate timing and technique, most urethral fistulas can be successfully repaired. Prognosis depends on several factors:

• Location of the fistula site: Fistula far away from the coronal region can be repaired by simple closure.
• Tissue quality: Healthy, non-scarred tissue improves the likelihood of long-term closure.
• Number of previous repairs: Each additional surgery slightly reduces the success rate due to increasing tissue scarring and reduced vascularity.
• Surgeon’s experience: Experienced pediatric urologists have higher success rates for complex repairs.

Conclusion

Urethral fistula is the most common complication after hypospadias repair, but with proper diagnosis, patient selection, and surgical technique, most cases can be effectively managed. Families and patients should be reassured that while the development of a fistula is distressing, it can often be successfully treated, and most children go on to have normal urinary and functional outcomes. If you suspect a urethral fistula or have concerns about post-hypospadias surgery care, it is important to consult a pediatric urologist or specialized hypospadias surgery team for
individualized assessment and management.

About Hypospadias Foundation

Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with best surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.

Hypospadias is a condition seen in 1 in 150 to 200 newborn boys. Surgical repair is the primary treatment for hypospadias, aiming to reposition the urethral opening to the tip of the penis, straighten any abnormal curvature and to improve the overall appearance of the penis. Like any other surgery, complications can occur even after hypospadias repair. The common complications which occur are urethrocutaneous fistula, meatal stenosis, glans dehiscence and rarely urethral diverticulum or urethral stricture. Among this the most common and notorious complication is the urethral fistula.

Urethrocutaneous fistula refers to the development of an abnormal opening between a newly constructed urethra and the skin on the underside of the penis. When this occurs the child or the adult will have more than one urine stream. There will be one stream from the tip of the penis (the newly created opening) and the other stream or leak of urine from the fistula site. The leaking of urine from the fistula site tends to fall on the legs or can wet the clothing causing inconvenience to the children and the adult. In our centre, we see lot of children coming for urethral fistula treatment after first surgery somewhere else like the case below.

Post hypospadias surgery fistula can occur due to multiple reasons. Some of them are as follows:

1. Intraoperative factors:

a. Poor blood supply: Poor blood supply also called as ischemia is one of the most common factors that can severely impair and delay tissue healing. The process of wound healing is complex and heavily relies on the continuous supply of essential nutrients along with oxygen via the blood stream. During urethroplasty if the blood supply of the tissues is poor then fistula formation can occur post-surgery due to poor healing.

b. Inadequate tissue closure: During urethroplasty, we must take care that there should be a watertight closure of the newly reconstructed passage. And this urethral passage should be reinforced with multiple layers of tissues such as local tissues or dartos flap so that the risk of fistula formation decreases. Gaps in the urethral closure with deficient overlying tissue layers can increase the risk of fistula formation.

c. Tight closure of tissues: The urethroplasty and overlying tissue closure in hypospadias should never be under tension. If the tissue closure is tight then the vascularity is affected and can cause ischaemia of the tissues leading to skin necrosis and fistula formation.

d. Narrow or stenosed urethra: The newly reconstructed urethra in hypospadias should be of good calibre. If the urethra becomes narrow, then there can be increased pressure within the urethra proximal to the narrow segment leading to a weaker point which gives away causing urine leaking from this pointwhich becomes a fistula.

e. Type and severity of hypospadias: Severe hypospadias or complex hypospadias is usually associated with severe penile curvature along with urinary opening situated far from the head of the penis. Longer urethral reconstruction is inherently more complex with higher risk of complications and hence higher chance of fistula formation compared to milder forms of hypospadias.

f. Fibrotic or unhealthy tissues: Fibrotic tissues are associated with poor blood supply and using such tissues for urethral reconstruction can be disastrous with higher possibility of dehiscence and fistula formation.

g. Surgeon experience: The risk of fistula formation will be higher at a centre performing very few hypospadias repairs compared to a centre performing more than 50-60 repairs every year. The technique, tissue handling etc gets better only once the surgeon performs more than 50 hypospadias surgeries every year.

2. Post operative factors:

1.Infection: If the operated hypospadias site gets infected in the post-surgery period, then there is a possibility of dehiscence at the site of infection which in turn can cause fistula formation.

2.Poor nutrition: Optimal nutrition is not just beneficial but fundamental for wound healing. Deficiency in key nutrients can cripple the body’s ability to repair itself leading to weakened tissue, increased infection risk and ultimately wound breakdown and higher chance of fistula formation

3.Presence of constipation: Constipation can indirectly contribute to wound breakdown. Straining to pass stool can put pressure on the penile area and can put undue stress on the delicate tissues and new sutures which can give away and cause fistula formation.

Inspite of the best efforts of the hypospadias surgeon, fistula can occur after hypospadias repair. Even if fistula occurs, there is a possibility that the fistula can close spontaneously. At Hypospadias Foundation, we wait for 6 months to assess the same and if it does not close then surgery in the form of fistula closure may be required. Before urethral fistula closure it is mandatory to check the urinary passage beyond the site of fistula. If the passage beyond the site of fistula is narrow, then simple urethral fistula closure may not suffice, and reconstruction of the entire distal passage (distal urethroplasty) may be necessary.

Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.

Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated more than thousands of children and adults with hypospadias with excellent results.

Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.

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.

Hypospadias surgery is a procedure to correct the opening of the urethra on the underside of the penis. It is one of the most common pediatric urological surgeries. Ensuring your child’s safety and comfort throughout the surgery is paramount. Anesthesia plays a crucial role in achieving this goal.

Types of Anesthesia for Hypospadias Surgery:

 General Anesthesia: The most common approach, general anesthesia renders your child unconscious and pain-free. Medications are typically
administered intravenously (through an IV) or via inhalation through a breathing mask. The anaesthesia is usually short and there is no significant
effect on the child.

 Regional Anesthesia: Regional anaesthesia is one which works only in the specific area of the body. The regional anaesthesia used in hypospadias
repair is a caudal block, an injection near the tailbone for targeted pain control. This caudal block gives good pain relief for six to eight hours and
sometimes even up to ten hours after hypospadias surgery. Older children may feel tingly and numb in the lower limbs and may find it difficult to walk till it wears off, usually within first 12 hours

 Combined Anesthesia: Combining general and regional anesthesia offers the benefits of both: comprehensive pain management during surgery and a smoother recovery from general anesthesia.

The anaesthesia medicines chosen in children is such that there are minimal side effects and, we can resume oral intake as early as 1-2 hours after the hypospadias correction surgery.

Pediatric Anesthesiologists:

Anesthesia for hypospadias surgery is administered by a trained pediatric anesthesiologist, a medical doctor specializing in anaesthesia for infants and children and takes good care before, during, and after hypospadias repair surgery. They will meticulously assess your child’s health before hypospadias surgery, discuss anesthesia options, and choose the safest and most suitable approach for your child’s individual needs.

Communicate and Ask Questions:

Open communication with your child’s hypospadias surgeon & urologist and anesthesiologist is vital. Don’t hesitate to ask questions regarding the anesthesia plan and any concerns you may have. Feeling informed and involved in your child’s care can significantly ease anxieties.

At Hypospadias foundation, we have trained pediatric anesthesiologists who have managed more than thousands hypospadias correction repairs. From airway management, right medications to post operative pain relief we believe in a complete care of the child from pre surgery to post surgery. Safe and effective anaesthesia is necessary for good post operative recovery after hypospadias surgery.

Effective Pain Relief After Hypospadias Surgery

Pain relief is very important especially in a child because a cranky child makes the parents and the hypospadias surgeon anxious. After any procedure, it’s natural for your child to experience some discomfort but the discomfort should be manageable. Here’s a guide to effective pain relief after hypospadias surgery:

Doctor-Prescribed Medications:

 Pain relievers: After surgery we prescribe pain medications, often starting with acetaminophen(paracetamol) or ibuprofen. The medicines must be given as advised because good pain relief means a comfortable child and in turn leads to good healing after hypospadias repair.

 Antibiotics: To prevent infection, antibiotics are prescribed after hypospadias surgery. They must be continued till the catheter removal and
sometimes for a few days even after the hypospadias catheter is removed. Infection can destroy the entire hypospadias repair hence we need to be
vigilant and avoid infection at all costs.

 Bladder antispasmodics: The presence of a urinary tube can cause urinary bladder contractions. The only way to manage this is by prescribing anti spasmodic medicines. Hence after hypospadias surgery till the catheter removal, the child will be on anti-spasmodic medicines.

 Pain due to erection: Painful erections after hypospadias surgery occur in every child and are even more prominent in teenagers and adults. This pain can be quite bad due to swelling of penis and the presence of a urinary tube. Hence we prescribe a stronger painkiller diclofenac in the form of
suppository during these episodes of severe pain. This medicine gives good pain relief in times of extreme pain. For adults we also add more medicine to decrease painful erections at night.

At-Home Pain Management Strategies:

 Positioning: Encourage your child to rest comfortably, positioning themselves to minimize tension on the surgical area. This can be lateral or
supine position with pillow support.

 Distraction: Engaging your child in their favourite activities or games can help take their mind off any discomfort after hypospadias surgery

 Loose Clothing: Tight clothing can apply pressure on the operated site and cause discomfort to the child. Opt for loose-fitting clothing made from
breathable fabrics to avoid irritation.

 Dietary Adjustments: Prefer healthy nutritious food over processed food. Processed food does not have fibre and cause constipation in a child which in turn can cause bleeding at the operated site during straining. Maintaining hydration is also essential to prevent constipation.

 Hygiene: Maintain proper hygiene around the hypospadias surgical site as instructed by your doctor. Change inner diaper frequently when dirty and be vigilant for soling of dressing. If dressing gets dirty at any point, do visit the hospital and get a hypospadias dressing change.

 Activity Restrictions: Follow the doctor’s recommendations regarding activity levels to promote healing and prevent complications. Any vigorous
activities are generally avoided typically for 4-6 weeks after hypospadias surgery. Children can play at home and other board games comfortably.

Remember:

 Consult your Hypospadias Doctor: If pain seems excessive or worsens, consult your child’s doctor for further evaluation and possible medication
adjustments.

 Be Patient: Healing takes time after a hypospadias surgery. Be patient with your child and offer support throughout the recovery process.

At Hypospadias Foundation India, we have treated thousands of children and adults with hypospadias. Our approach to hypospadias repair includes
comprehensive care from preoperative to post operative period. Remember, every child heals at their own pace. By being prepared, informed, and supportive, you can help your child through this journey and ensure a successful recovery. Dr A.K.Singal and Dr Ashwitha Shenoy are rated as the best hypospadias surgeons in India. Their experience in the field of hypospadias makes them the best surgeons for hypospadias repair for both children and adults. 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 or visit us at the hospital.

Chordee is a condition where the penis is curved downward. Most of the times it is associated with hypospadias but can occur without hypospadias. Chordee correction is very crucial step during hypospadias repair. Without chordee correction, urethroplasty should not be attempted because there will be a stress of the urethral passage and there is high risk of complications after surgery.

Chordee surgery is usually successful in correcting the curvature of the penis completely. However, there is a small chance that chordee can come back after surgery. This is called recurrent chordee.

Risk factors for recurrent chordee:

• Incomplete correction of chordee: When the chordee is severe, it must be corrected completely during chordee correction surgery. If there is any residual chordee after chordee correction surgery, it will only worsen in the future.
• Fibrosis during healing: After chordee correction, fibrosis can occur on the underside of the penis during healing process. Sometimes the fibrosis can improve with steroid massage but if it persists then recurrent chordee correction may be required. This fibrosis can be at the level of skin, tissue under skin or even urethra.
• Due to flaps: Recently we have seen some cases where tunica vaginalis flaps were used for second layer cover during hypospadias surgery at other centres. Somehow the flaps didn’t heal well and they caused chordee to come back. Similar outcomes we have seen when a very tight urethra was made from prepucial flaps or koyanagi repair in first surgery.

Symptoms of recurrent chordee:

The common symptoms which children present with are downward bending of the penis, urine which goes backward and may have occasional pain during erections.

Adults with recurrent chordee may have pain during erection, inability to perform sexual intercourse, painful sexual intercourse and infertility

Treatment for recurrent chordee:

If you think you may have recurrent chordee or your child has recurrent chordee, it is important that you see a doctor right away. You need to visit a hypospadias surgeon or a pediatric urologist who has expertise in the field of hypospadias and chordee correction.

Chordee correction can be done by various methods. First and foremost, the cause for recurrent chordee has to be identified and then appropriate method is used to correct chordee. Chordee correction method differs for children and adults.

1. If a child presents with residual chordee due to incomplete chordee correction in the past, then the following methods of chordee correction are used: Complete degloving is done and chordee is assessed, if chordee persists even after degloving then the following methods are adopted.  If the chordee is due to short urethra due to flaps or tunica vaginalis flaps, we divide them at this stage.

Pre degloving and post degloving chordee assessment

(a) Dorsal tunica Albugenia Plication (TAP): If the chordee is less than 30 degree then it can be easily corrected by placing a non-absorbable suture at the site of maximum curvature on the dorsal side(upper side) of the penis. This will correct the chordee completely.

Post Degloving showed less than 30-degree chordee. 12’o clock dorsal tunica albuginea plication done. Chordee completely corrected by this plication.

No chordee noted after 12’o clock dorsal tunica albuginea plication

(b) Urethral plate division and Proximal urethral mobilization: If the chordee is more than 30 degrees then one of the reasons for persistent chordee is short urethra, in these cases we will have to divide the urethral plate ventrally and mobilize the proximal urethra. This will effectively correct chordee if it is due to congenital short urethra.

Urethral plate division and proximal urethral mobilization

(c)If chordee persists inspite of urethral plate division then urethral mobilization, ventral corporotomies are done. This will correct the chordee if the cause for chordee is due to disproportionate corporal bodies.

Three ventral corporotomies

(d) If none of the above measures can correct chordee then we perform a ventral lengthening procedure called as the dermal graft. Deep incision is given in the tunica on the ventral side at the site of maximum curvature and dermal graft is placed at the site. This method is adopted in cases of severe chordee.

Dermal graft

The chordee is corrected completely after the above steps of chordee correction.

2. If the child presents with severe chordee inspite of complete chordee correction in the past, then it is most likely due to ventral fibrosis. In these cases, along with some or all the above methods, removal of fibrotic tissues from the underside of the penis is important to correct the chordee.

Adults with recurrent chordee after previous surgery

In most of the adults at first we assess the fibrosis and degloving is done. If the chordee is still there, then we divide the urethral plate and mobilise it. Post this, if the chordee still persists, we can correct chordee completely by a method called as “16 dot plication”. In this method, 4 sutures are placed on either side of maximum curvature on the dorsal side, which will correct the chordee uniformly in an adult penis.

In most of the cases of recurrent chordee in addition to chordee correction, urethroplasty will also be required. In redo cases, chordee correction and urethroplasty will most likely be done in two to three stages and oral mucosa graft will be used in more than 95% of such cases. Only in few exceptional we may be able to repair everything in single stage.

About Hypospadias Foundation India:

Hypospadias Foundation in Navi Mumbai, India is dedicated to offering care and cure for chordee and hypospadias in children and adults. Set up in 2008, more than 3000 children and adults have benefitted from care and achieved best in class results for chordee and hypospadias. Dr A.K.Singal and Dr Ashwitha Shenoy, hypospadias expert surgeons at Hypospadias foundation have dedicated their lives to the art and science of hypospadias repair.

If you feel your child or you are suffering from recurrent chordee even after previous chordee correction, then do get it checked by an expert pediatric urologist or a hypospadias surgeon. Chordee correction surgery has good result when done in childhood than in adulthood. Do not hesitate to write to us or contact us

Contacting the Hypospadias Foundation:

• Website: https://www.hypospadiasfoundation.com/
• Email: hypospadiasfoundationindia@gmail.com
• Phone:
  • +916262840940
  • +916262690790
  • +919324180553(whatsapp and teleconsult)

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

Keywords: recurrent chordee, residual chordee, chordee repair, chordee repair surgery, chordee correction surgery, bent penis repair, best hospital for hypospadias in india, best hypospadias surgeon, hypospadias repair in india, adult chordee repair, dermal graft repair, 16 dot plication for chordee

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)

Fill up contact form: https://www.hypospadiasfoundation.com/contact/

Surgery Steps:

Marking of the degloving incision, a crucial step in surgery for distal hypospadias and penile torsion, commenced the procedure. Local anesthesia was meticulously infiltrated at the marked incision site to ensure patient comfort. The surgical process proceeded with complete degloving and assessment of chordee, revealing a 30-degree chordee. Chordee correction was expertly performed through Tunica albuginea plication at 12 o’clock on the dorsal side, resulting in the successful elimination of chordee. Urethroplasty commenced with precise incision of the urethral plate in the midline, followed by meticulous suturing over a 7Fr Infant feeding tube with 6-0 PDS continuous sutures. Additional measures included the harvesting of a Dartos flap for extra coverage over the urethroplasty, secured with 6-0 PDS sutures. Penoscrotal web correction was also addressed, with excess skin excised and meticulously sutured using 5-0 vicryl rapide. To address penile torsion, skin flaps were rotated and adjusted, ensuring optimal alignment, and meticulously sutured all around using 5-0 vicryl rapide. Postoperative care included a 7-day period with dressing and catheter in situ, followed by their removal to facilitate the patient’s recovery.

Results

The Final result was very gratifying with a straight penis without any torsion. The child was passing urine in good stream in straight axis without any discomfort or pain.

About Hypospadias repair and penile torsion

Penile torsion is a condition wherein the penis is rotated or twisted on its axis. The penile torsion is more commonly to the left. Many a time penile torsion may not be detected till a circumcision is planned or foreskin is retracted.

Penile torsion may be associated with hypospadias and/or chordee (penile curvature). With hypospadias, penile torsion is mostly associated with distal penile cases.

Based on the degree of glanular rotation, penile torsion can be classified as mild, moderate, and severe. It is mild if its less than 45 degree, moderate if it’s between 45-90 degree and severe if more than 90 degree.

Penile torsion in majority of cases (>85%) is between 10 to 20 degree. If it is a moderate or severe degree of torsion, urine stream may be deviated to one side.

Surgical intervention is not always required in isolated penile torsion. The indications for surgical correction are cosmetic, functional, or sexual. When penile torsion is associated with hypospadias, it should be corrected along with Hypospadias repair or urethroplasty at the same time.

About Hypospadias Foundation

Hypospadias foundation is a centre which provides personalized and best quality care for children and adults with hypospadias. It is one of the best hospital centres in India and world for surgical treatment for hypospadias in adults and children.  Our dedication in the field of hypospadias has helped us achieve excellent outcomes in these patients. We treat children and adults not only from various parts of India but also from more than 25 countries all over the world. Hypospadias foundation is located at MITR hospital in Kharghar, Navi-Mumbai, Maharashtra, India. Every year more than 200 surgeries for hypospadias are performed at MITR hospital and Hypospadias Foundation

Contact us:

For appointment kindly contact us at the contact details given below.

• MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India
• MITR Clinic: C1/8 Ground floor, Sector-2, VashiCall

Call for appointments: +91-2227743558/ 27744229/ 39/69 and +919324180553.

Or you can fill up this form- Contact form for Dr Singal

Fill up contact form: https://www.hypospadiasfoundation.com/contact/