Hypospadias & epispadias

1. PRESENTED BY
MR.ROMAN BAJRANG
RELIANCE INSTITUTE OF NURSING

4. HYPOSPADIAS
 The term hypospadias refers to a urethral opening
that is on the ventral surface of the penile shaft,
proximal to the end of the glans. The meatus may be
located anywhere along the shaft of the penis, from
the glans to the scrotum, or even in the perineum.
 Some boys with hypospadias, particularly those with
proximal hypospadias, have chordee, in which there
is ventral penile curvature during erection.

5.  Hypospadias occurs in up to 4 in 1,000 newborn boys.
 The reason why the penis does not develop properly is
still not clear.
 The development of the penis whilst the baby is
growing in the womb is partly dependent on the male
sex hormones such as testosterone.
 The effects of testosterone on the growing penis may
be blocked in some way.
 Although it is not a genetic condition, hypospadias can
run in some families

6. CAUSES
 present at birth (congenital). The exact reason this
defect occurs is unknown.
 A defect in the androgen stimulation of the
developing penis.
 the deficient androgen production by the testes
and placenta.

7.  Age and weight: Mothers who were age35 years or older and
who wereconsidered obese had a higher risk of having a baby
with hypospadias.
 Fertility treatments: Women who usedassisted reproductive
technology to help with pregnancy had a higher risk of having a
baby with hypospadias.
 Certain hormones: Women who took certainhormones just
before or during pregnancy wereshown to have a higher risk of
having baby with hypospadias.
 Exposure to smoking and chemicals: There is some
speculation about an association between a mother's exposure
to pesticides and hypospadias.
 Family history: This condition is more common in infants with
a family history of hypospadias.

8. by Duckett in 1996.
 He divided them into anterior (50%), middle
 (30%) and posterior (20%) hypospadias.
- The anterior form: glandular, coronal and distal
penile.
- The middle form: "midshaft" and proximal penile.
- The posterior form: penoscrotal, scrotal and
perineal

9.  Glanular hypospadias : the urethra is within the head of
his penis(glans).
 Coronal: The opening of the urethra is just below the head
of his penis.
 Distal penile: the opening of theurethra is in the distal
portion of the shaft of the penis .
 Midshaft: The opening of the urethra is located along the
shaft of the penis.
 Proximal penile: the opening of the urethra is in the
proximal portion of the shaft of the penis .
 Penoscrotal: The opening of the urethra is located where
the penis and scrotum meet.
 Scrotal hypospadias: hypospadias with the urethral
opening on the scrotal surface.
 perineal hypospadias: the urethral meatus opens in the
perineum near the anus; the scrotum is usually cleft.

11. CLINICAL MANIFESTATIONS
Mild hypospadias usually does not cause
symptoms, especially in newborns and young children.
This condition may cause a downward curve of the
penis during an erection.
Erections are common in infant boys.

12. OTHER SYMPTOMS
INCLUDE
Abnormal spraying of urine
. Having to sit down to urinate
. Foreskin that makes the penis looks
like it has a "hood"
The farther the opening is from the tip
of the glans, the more likely curvature
in the penis (chordee) is present.

13. DIAGNOSTIC MEASURES
. prenatal ultrasound
. Physical exam of a newborn: upon examination, the
foreskin is usually incomplete and the misplaced
urethral opening is located.
. Excretory urogram: This test uses X-rays to provide
pictures of the urinary tract, and other congenital
anomalies

14. TREATMENT
1. Medical management
Minor cases of hypospadias, in which the meatus is
located up toward the tip of the glans, may not require
surgical repair and may simply be managed with
observation.
2. Adjuvant hormonal therapy
Presurgical treatment with testosterone injections or
creams, as well as HCG injections, to promote penile
growth, and for the improvement in chordee with
lessening in the severity of the hypospadias.

15. Management begins in the newborn period.
Circumcision should be avoided, because the
foreskin often is used in the repair.
The ideal age for repair in a healthy infant is 6-12
months
-There is no greater risk of general anesthesia at this
age compared to 2-3 yr
-Penile growth over the next several years is slow
- The child does not remember the surgical procedure
-Postoperative analgesic needs are less than in older
children

16. DIFFERENT SURGERIES
1.Glandular hypospadias requires a
glandular meatotomy .
2.Coronal hypospadias requires a meatal
advancement and glanduloplasty (MAGPI
operation) .
3.Proximal hypospadias without a chordee
can be treated by a skin flap advancement
.
4.If chordee present it should be excised

18. Epispadias is a congenital malformation in
which the opening of the urethra is on the
dorsum of the penis.
. In boys with epispadias, the urethra
generally opens on the top or side of the
penis rather than the tip. However, it is
possible for the urethra to be open along
the entire length of the penis.
. In girls, the opening is usually between
the clitoris and the labia, but may be in the
belly area.

19. CAUSES
•Unknown .
• Related to improper development of the pubic
bone .
•Failures of abdominal and pelvic fusion in the
first months of embryogenesis .
• Epispadias can be associated with bladder
exstrophy, an uncommon birth defect in which
the bladder is inside out, and sticks through the
abdominal wall .
•Also occur with other defects .

20. CLASSIFICATION
Classification of epispadias is based on the
location of the meatus the penis. It can be
positioned: On the glans (glanular)
. Along the shaft of the penis (penile)
. Near the pubic bone (penopubic)
The position of the meatus is important because
it predicts the degree to which the bladder can
store urine (continence). The closer the meatus
is to the base of the penis, the more likely the
bladder will not hold urine

21. SYMPTOMS
IN MALES :
1.Abnormal opening from the joint between the
pubic bones to the area above the tip of the
Penis .
2. Backward flow of urine into the kidney (reflux
nephropathy)
3.Short, widened penis with an abnormal
curvature
4.Urinary tract infections
5.Widened pubic bone

22. In females:
Abnormal clitoris and labia
•Abnormal opening where the from the
bladder neck to the area above the normal
urethral
opening
•Backward flow of urine into the kidney
(reflux nephropathy) Widened pubic bone
•Urinary incontinence
•Urinary tract infection

23. DIAGNOSTIC MEASURES
Prenatal diagnosis - rare
. Blood test to check electrolyte levels
. Intravenous pyelogram (IVP), a
special x-ray of the kidneys, bladder,
and ureters
. MRI and CT scans, depending on the
condition
. Pelvic x-ray

24. SURGICAL TECHNIQUE IN
MALES
•The modified Cantwell technique
It involves partial disassembly of the penis and
placement of the urethra in a more normal
position.

25. TREATMENT
The primary goals of treatment of epispadias are
to:
•maximize penile length and function by
correcting dorsal bend and chordee; and
•create functionality and cosmetically acceptable
external genitalia with as few surgical
procedures as possible.
•If the bladder and bladder neck are also
involved, surgical treatment is required to

26. The second technique is the Mitchell technique.
> It involves complete disassembly of the penis
into its three separate components.
> Following disassembly, the three components
are reassembled such that the urethra is in the
most
functional and normal position and dorsal
chordee is corrected.

27. Surgical technique in females :
•The urethra and vagina may be short and near
the front of the body and the clitoris is in two
parts.
•If diagnosed at birth, the two parts of the clitoris
can be brought together and the urethra can be
placed into the normal position.
•If repaired early enough, lack of urinary control
(incontinence) may not be a problem.

28. •If the diagnosis is missed or if early repair is not
performed, then incontinence can be surgically
corrected at the time of diagnosis.
•If the vaginal opening is narrow in older girls or
younger women, reconstruction can be
performed after puberty.