2022 - Hypospadias Flashcards

1
Q

What is hypospadias, and what does it include?

A

Hypospadias is a common congenital anomaly in boys with a prevalence of 1 in 150 to 300 live births. It includes a dorsally hooded foreskin, an ectopic urethral meatus, and ventral penile curvature. Severity varies, and in mild cases, surgery may not be necessary.

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2
Q

How was hypospadias traditionally classified, and what are the current important considerations?

A

Hypospadias was traditionally classified based on the location of the urethral meatus, with 70%–85% having a distal variant and 10%–25% a proximal variant. Now, the degree of penile curvature, glans anomaly, and shaft skin deficiencies also play a role in classification and complications.

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3
Q

What are the goals of penile reconstruction in patients with hypospadias?

A

The goals include allowing the boy to void upright with normal velocity and laminar flow, obtaining satisfactory sexual function with a straight penis, and creating an orthotopic meatus with a well-approximated glans. The varied nature of hypospadias makes this a unique challenge.

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4
Q

What are the success rates and common complications of distal and proximal hypospadias repairs?

A

Distal hypospadias repairs have an 85%–95% success rate, while proximal repairs have higher complications (35%–68%). Common complications include urethrocutaneous fistula, glans dehiscence, meatal stenosis, recurrent chordee, stricture disease, and diverticula.

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5
Q

What is the most common complication after hypospadias repair, and how is it managed?

A

The most common complication is urethrocutaneous fistula, with a 10% incidence. Causes are multifactorial, and management depends on factors like number, size, and location. Primary repair or redo urethroplasty might be required.

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6
Q

What is glans dehiscence, and when does it occur?

A

Glans dehiscence is a complication identified early postoperatively, usually resulting from undue tension on the glans closure. Reoperation may not be necessary unless voiding symptoms are bothersome.

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7
Q

What causes meatal stenosis, and how is it treated?

A

Meatal stenosis may occur when the neomeatus is extended too far or due to a technical issue with incomplete glans wing dissection. Treatment may include repair, conservative management with topical steroids and dilation, or re-do urethroplasty.

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8
Q

What are the considerations in managing urethral stricture after hypospadias repair?

A

Urethral stricture’s management depends on the caliber, location, and length of the stricture. Treatment may include dilation, direct vision urethrotomy, or revision urethroplasty with buccal mucosal graft or local skin flaps.

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9
Q

What is urethral diverticula, and what are its common symptoms?

A

Urethral diverticula is a complication that may cause post-void dribbling, weak stream, ventral penile bulge with voiding, or UTIs. It is more common after specific repairs, including proximal repairs, due to the lack of natural spongiosal tissue reinforcement.

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10
Q

How is ventral curvature associated with proximal hypospadias managed?

A

Ventral curvature in proximal hypospadias must be objectively measured. Mild curvature (<30 degrees) can be managed with dorsal plication, while moderate to severe curvature requires ventral lengthening.

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11
Q

Why is extended follow-up essential after hypospadias repair?

A

Extended follow-up is crucial to recognize complications, as many occur after the first year, and some even more than 5 years postoperatively. Surgeons should follow patients through puberty to identify high-risk individuals.

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12
Q

How is postoperative urinary function assessed after hypospadias repair, and what are common findings?

A

Postoperative urinary function assessment includes office uroflowmetry (UF), revealing normal maximum urine flow rate (Qmax) values but below the 50th percentile compared to age-matched controls. Obstructive flow rates vary between distal (15%–33%) and proximal (75%) repairs.

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13
Q

What lower urinary tract symptoms may adult patients present after hypospadias repair?

A

Adult patients may present with symptoms like slow/weak stream (15.1%), spraying/splayed stream (30%), or post-void dribbling (29.6%). These symptoms are reported twice as often in patients with hypospadias repair, and underlying pathological causes should be investigated.

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14
Q

How can hypospadias surgeries during infancy affect sexual function and satisfaction?

A

Hypospadias surgeries can have lasting effects on sexual behavior and self-esteem. Recent literature shows comparable sexual debut, interest, libido, and satisfaction with controls. Surgical efforts aim to preserve erectile function and sensation.

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15
Q

What is known about erectile dysfunction after hypospadias repair?

A

Erectile dysfunction prevalence is complex and multifactorial. Proximal hypospadias repair has a 2 to 4-fold increased risk of mild to moderate dysfunction compared to distal. Severity correlates with response to oral phosphodiesterase-5 inhibitor therapy.

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16
Q

How does perceived penile length affect sexual satisfaction after hypospadias repair?

A

Perceived decreased penile length can cause dissatisfaction with sexual function and cosmesis. Ventral lengthening has been shown to add length, and awareness of this concern helps in patient counseling.

17
Q

How do meatal position and ejaculation affect satisfaction after hypospadias repair?

A

Surgeons often prioritize meatal position more than patients. Orgasmic function is preserved, but issues with ejaculation, such as post-orgasmic milking of the urethra, can occur. Surgical restoration of projectile ejaculatory function is currently limited.

18
Q

How can hypospadias impact fertility, and what evaluation is needed?

A

Hypospadias can impair fertility due to issues with sperm production, quality, and erectile/ejaculatory function. Evaluation should include reproductive hormone profiles, semen analysis, physical examination, and detailed history.

19
Q

How do semen parameters and fertility outcomes compare in adult men after hypospadias repair?

A

Adult men after hypospadias repair generally have normal semen parameters. However, proximal hypospadias and associated disorders can impair fertility. These men may have a lower probability of having a biological child and use assisted reproductive technology more often.

20
Q

What factors may contribute to decreased paternity rates in men with hypospadias?

A

Decreased paternity rates may be due to underlying subfertility, testicular dysgenesis, psychosocial behaviors, sexual dysfunction, associated conditions like cryptorchidism, or meatal ectopia impacting semen deposition.

21
Q

What are the psychosocial aspects of adult hypospadias patients, and why is long-term follow-up necessary?

A

Adult hypospadias patients often feel embarrassed and discouraged due to multiple failed repairs. Long-term follow-up through sexual maturity is needed to detect latent complications and mitigate psychosocial barriers to care.

22
Q

What are the common and uncommon complications that adult hypospadias patients might present with?

A

Common: urethral strictures (45%–72%), urethrocutaneous fistulae, persistent hypospadias, ventral curvature, UTI, lichen sclerosis. Uncommon: genitourinary pain, hair-bearing urethral tissue, bladder/urethral stones, infertility, buried penis.

23
Q

What are the key aspects of evaluating an adult hypospadias patient?

A

Evaluation includes a detailed history of previous repairs, physical examination (urinary stream, ventral shaft skin, glans size), and diagnostic evaluation (UF, post-void residual, urine studies, retrograde urethrogram, cystoscopy). This guides surgical decisions.

24
Q

How should persistent lower urinary tract symptoms and UTIs be managed in adult hypospadias patients?

A

The workup should rule out surgically correctable conditions. Conservative management can include alpha-blockers, anticholinergics, intermittent catheterization, physical therapy, and biofeedback. Tailored treatment is critical for patient-centered care.

25
Q

What makes urethral strictures unique in adult hypospadias patients, and how are they managed?

A

Urethral strictures in adult hypospadias patients are typically associated with poorer quality tissues and are often longer. They may require complex staged surgical interventions. Referral to a reconstructive specialist might be necessary given the complexity.

26
Q
A
27
Q

What is the prevalence of hypospadias in the United States, and what does it imply for adult urology practice?

A

Hypospadias occurs in 1:200 male births in the United States. Though not all undergo surgery, the cumulative number necessitates an understanding for the adult urology practice.