HYPOSPADIAS PRESENTATION

1. HYPOSPADIAHYPOSPADIA
SS
DR.ALEX ELIFURAHA MSOKA (TANZANIA)DR.ALEX ELIFURAHA MSOKA (TANZANIA)
GENERAL SURGERY RESIDENTGENERAL SURGERY RESIDENT
DEPARTMENT OF SURGERYDEPARTMENT OF SURGERY
ALEXANDRIA UNIVERSITY(EGYPT)ALEXANDRIA UNIVERSITY(EGYPT)
24 -03-201824 -03-2018

3. DEFINITIONDEFINITION
 External urethral meatus opens on theExternal urethral meatus opens on the
ventral side of the penis proximal to theventral side of the penis proximal to the
glansglans
 The penis is more likely to haveThe penis is more likely to have
associated ventral shortening andassociated ventral shortening and
curvature called chordee with morecurvature called chordee with more
proximal urethral defects.proximal urethral defects.
 Occur in 1 out of 300 live maleOccur in 1 out of 300 live male
births,higher in whites than blacksbirths,higher in whites than blacks

4. PATHOGENESISPATHOGENESIS
 Sexual differentiation and urethral developmentSexual differentiation and urethral development
occurs 8-15 weeks of intrauterine lifeoccurs 8-15 weeks of intrauterine life
 The classic theory, Urethra is formed by theThe classic theory, Urethra is formed by the
fusion of urethral folds (from urogenital sinus)fusion of urethral folds (from urogenital sinus)
along the ventral surface of the penis and italong the ventral surface of the penis and it
extends distally to the coronaextends distally to the corona
 Glandular urethra is formed by canalization of anGlandular urethra is formed by canalization of an
ectodermal cord.ectodermal cord.

5. PATH…PATH…
 This ectodermal cord grows through theThis ectodermal cord grows through the
glans to communicate with previouslyglans to communicate with previously
fused urethral folds at coronafused urethral folds at corona
 Hypospadias occurs when fusion of theHypospadias occurs when fusion of the
urethral folds is incompleteurethral folds is incomplete

6. TRIAD OF HYPOSPADIASTRIAD OF HYPOSPADIAS
 Hypospadias usually consists of theHypospadias usually consists of the
following three componentsfollowing three components
1.1. Ventral urethral openingVentral urethral opening
2.2. Chordee-as a result of fibrosisChordee-as a result of fibrosis
3.3. Dorsal hood-fore skin (prepuce) on the dorsum ofDorsal hood-fore skin (prepuce) on the dorsum of
the penisthe penis

9. ASSOCIATED ANOMALIESASSOCIATED ANOMALIES
 Anterior and middle type is associatedAnterior and middle type is associated
with Cryptorchidism 9.3% and Congenitalwith Cryptorchidism 9.3% and Congenital
Inguinal Hernias (9%) with more severe IInguinal Hernias (9%) with more severe I
30/20.30/20.
 Posterior type is associated with IntersexPosterior type is associated with Intersex
(ambiguous genitalia)(ambiguous genitalia)

10. Other anomaliesOther anomalies
 Wilms tumour- Beckwith-Wiedemann syndromeWilms tumour- Beckwith-Wiedemann syndrome
 Spina bifida-meningomyeloceleSpina bifida-meningomyelocele
 High type imperforate anusHigh type imperforate anus
 Renal ectopiaRenal ectopia
 Horseshoe kidneyHorseshoe kidney
 Bilateral cystic diseaseBilateral cystic disease
 Micropenis with prostatic utricleMicropenis with prostatic utricle

11. OUTCOME OF HYPOSPADIASOUTCOME OF HYPOSPADIAS
 Voiding dysfunctionVoiding dysfunction
 Sexual problems-abnormal and painfulSexual problems-abnormal and painful
erection and infertilityerection and infertility
 Social stigma-psychosexualSocial stigma-psychosexual
 Other problems associated with otherOther problems associated with other
anomalies e.g. cryptorchirdism, hernia,anomalies e.g. cryptorchirdism, hernia,
intersexintersex

12. DIAGNOSISDIAGNOSIS
 HistoryHistory
1.1. Abnormal urethral opening and voidingAbnormal urethral opening and voiding
2.2. History of familial pattern of hypospadiasHistory of familial pattern of hypospadias
3.3. Associated anomalies-cryptorchidism, herniasAssociated anomalies-cryptorchidism, hernias
etcetc
4.4. IVF has been associated with higher incidienceIVF has been associated with higher incidience
of hypospadiasof hypospadias

13. Diag…Diag…
 ExaminationExamination
1.1. Local examination focusing on meatalLocal examination focusing on meatal
location,glans configuration,skin coverage andlocation,glans configuration,skin coverage and
chordee .chordee .
2.2. Other associated anomaliesOther associated anomalies

14. INVESTIGATIONSINVESTIGATIONS
 Investigations are divided into twoInvestigations are divided into two
depending on severity of the diseasedepending on severity of the disease
 In mid-moderate hypospadias, simpleIn mid-moderate hypospadias, simple
investigations routinely done include:-investigations routinely done include:-
1.1. Routine FBP, Bleeding time, serum createnine,Routine FBP, Bleeding time, serum createnine,
urinalysis and +/- urine cultureurinalysis and +/- urine culture
2.2. Radiological-abdominal & pelvic ultrasound, IVU,Radiological-abdominal & pelvic ultrasound, IVU,
MCU (these will r/o other associated congenitalMCU (these will r/o other associated congenital
anomalies.anomalies.

15. Invest…Invest…
 In severe hypospadias special investigationsIn severe hypospadias special investigations
done depending on the associated problem.done depending on the associated problem.
They include:-They include:-
1.1. Hormal assay- hCG(important for fetal testosteroneHormal assay- hCG(important for fetal testosterone
production), testosterone, cortisolproduction), testosterone, cortisol
2.2. Buccal smear and Karyotyping to establish genetic sexBuccal smear and Karyotyping to establish genetic sex
3.3. Urethro-cystoscopy and examination under anesthesia-r/oUrethro-cystoscopy and examination under anesthesia-r/o
other associated congenital anomaliesother associated congenital anomalies

16. TREATMENTTREATMENT
 Approach considerationApproach consideration
 The treatment of hypospadias is surgical repairThe treatment of hypospadias is surgical repair
for functional and cosmetic reasons.It isfor functional and cosmetic reasons.It is
recommended that it is done in the 1recommended that it is done in the 1stst
year ofyear of
life(4 to 18 months)life(4 to 18 months)

17. Treat…Treat…
 Medical treatmentMedical treatment
 For microphallus-testosterone injection orFor microphallus-testosterone injection or
cream,hcgcream,hcg
 Injection testosterone emanthate i.m 2mg/kgInjection testosterone emanthate i.m 2mg/kg
weekly increases the phallus size up to 50%weekly increases the phallus size up to 50%

18. Surgery…Surgery…
 The following are the main principles ofThe following are the main principles of
hypospodias repair regardless ofhypospodias repair regardless of
technique employedtechnique employed
 Orthoplasty(penile straightening)-correction ofOrthoplasty(penile straightening)-correction of
chordee.chordee.
 Urethroplasty-creation of neourethra throughUrethroplasty-creation of neourethra through
primary tubularization,flaps,graft or meatalprimary tubularization,flaps,graft or meatal
advancement procedures.advancement procedures.
 MeatoplastyMeatoplasty
 Glanduloplasty-To reform glans to moreGlanduloplasty-To reform glans to more