Paediatric Surgery & Paediatric Urology

 

 

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Phimosis/Circumcision

Undescended Testis, Hernia, Hydrocele

Hypospadias, Intersex

Hydronephrosis (PUJ) Pyeloplasty, Posterior urethral valves (PUV)

Urinary Tract Infection/ Vesico Ureteric Reflux

Urinary Stones in Children

Eneruresis, Bedwetting, Urinary Incontinence, Neuropathic bladder

Paediatric Laparoscopic Surgery (Key Hole Surgery)

Common Paediatric Surgical Problems

Bladder Exstrophy, Multi Cystic Kidney, Wilms Tumor, Emergencies

 

Hypospadias

Little baby boys pass urine like a fountain. Small lads can stand and pass urine straight with an ability to point the stream where they want, like a fire-manís hose. This is possible because the urine comes out of the opening at the tip of the penis.

In boys with hypospadias, the opening is located on the under surface of penis. Because of this the urine is deviated downwards towards their feet. The picture shows normal arrangement and hypospadias.

How is hypospadias detected? 

Hypospadias occurs in one in 300 male newborns. When the paediatrician checks out the baby, or when the parents bath the baby, the following features can make one suspect hypospadias

bulletUrine opening on the under surface of the penis
bulletPenis being slightly bent downwards
bulletExcess foreskin on the top of the penis

What are the consequences of Hypospadias?

 When hypospadias is left uncorrected, the following consequences can develop

  1. Unlike the normal lads who can stand and pass urine, hypospadiac lads have to sit; if they stand and pass urine, it goes down the leg.

  2. When they get older, because of the bent in penis, sexual activities become difficult. Also they have much lower chance to have children, as they canít deposit the sperm normally. The sperm leaks out through the opening located underneath.
  3. Sometimes the urinary opening is also small, leading to blockage in urine stream. This leaves them at a risk of urinary infection.

Do they have other birth defects? Can the same problem recur in future children?

In general, hypospadiac children do not have other kidney abnormalities. However in 10% of these kids, the testis may not be descended normally. When both testes have not come down normally, they can have associated hormone defects. When the first child or the father has hypospadias, there is a slightly higher chance (7-10%) for the future boys in the family to have the same birth defect.

What is the right time to correct hypospadias?

From 6 months onwards, hypospadias can be corrected by an operation. By completing the operation before 2-3 years of age, these children can be toilet trained normally like any other child. Not having an appearance like other boys at school, can lead to emotional problems in these children.

What does the operation involve? What are the complications?

Most of the hypospadias belong to the mild variety and can be operated by a single stage operation. When the opening is too far down from the tip, they might require two-stage operation. The operation is usually done under general anesthesia and a catheter/ dressing is left for 5-7 days. Three things are corrected during the operation.

  1. The opening is brought to the tip
  2. The penis is straightened
  3. Excess foreskin is removed (circumcision.

Optical magnification (microscope) and fine suture materials are essential for a successful result. When extra care is taken there is a very good (95%) success rate. In 5% the following complications can occur. 

  1. The new opening gets small gradually (meatal stenosis)
  2. Urine leaks at the original site (Fistula)

Both these can be corrected by another minor operation; so the parents need not have undue concern about this.

What are the chances of fertility after operation?

Straight penis and an opening at the tip are essential for a successful married life and fertility. When the problem is corrected by 1-3 years of age with a good outcome, there should be no problem in future for fertility.

 Key Points: 

bulletIn children with hypospadias, the opening is on the under surface of penis.
bulletBecause of this, these lads canít stand and pass urine like normal children.
bulletThey can have infertility in later life, if left uncorrected.
bulletBy performing a corrective surgery at the right age, these can be avoided.

 

Intersex

The first question asked by grandparents after a baby is born is 'is it a boy or girl'. This is often determined by looking at the genitalia. Intersex is a condition where the sex of the child could not be determined looking at the genitalia.

What are the causes of intersex?

The causes of intersex are many however it can be simplified as follows

bulletA Hypervirilised Girl: chromosome is XX but genitals are masculanised due to exposure to male hormones
bulletA Undervirilised Boy: Chromosome is XY but the genitals are not well masculanised due to deficiency or failure of action of male hormones
bulletMixture of problems: This can be at various levels; both XX and XY chromosomes or both testicular and ovarian tissues or multiple patterns

How to deal with this at birth?

It is essential to do the tests like chromosomes and harmonal tests soon after the birth to identify the problem. It is also essential not to name or fix gender for the baby before diagnosis. Once the problem is assessed doctors and parents should sit together and decide what is the best sex of rearing for the baby. If the sex is assigned by appearances without proper testing, it becomes socially very difficult to change gender once the child becomes old.

Can the appearance be improved by an operation?

Corrective surgery for intersex (to make them look more like a girl or to look more like a boy) is a complex procedure. Often the social implications and the social stigma of bringing up a child with abnormal genital force the parent to seek operation.

However it should involve a lot of thinking as they are irreversible and may involve altering sensation to the area. Although the sex assignment is done with the best interest by the parents and doctors, one should understand that the children may feel the other way and choose an opposite gender when they grow in to an adult.

Dr. Ramesh Babu, MS, MCh, FRCS, Paediatric Surgeon, Paediatric Laparoscopic Surgeon and Paediatric Urologist Chennai. For further information contact: drrameshbabu1@gmail.com; Mobile 9840359062

 

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Last modified: 06/19/06