Hypospadias can be divided into four types depending on the location of the urethral opening as follows.
1.Head of the penis, coronal sulcus type.
2.Penile body type.
3, penile scrotal type.
4, perineum type.
Since the degree of penile hypospadias is not proportional to the position of the urethral opening, some anterior hypospadias are combined with severe penile hypospadias. In order to facilitate the estimation of surgical results, the method of typing by the position of urethral recession after correction of penile hypospadias is accepted by many people, and this typing includes.
1. the anterior segment type, in which the post-correction urethral orifice is located at the head of the penis or the coronal sulcus.
2. mid-segment type, where the corrected posterior urethral orifice is located in the body of the penis
3, Posterior segment type: the corrected posterior urethral orifice is located at the penile scrotal junction or perineum.
Causes of morbidity.
The characteristic defect of hypospadias may arise from one or more of the following factors.
1. abnormal production of fetal testicular androgens.
2. restricted sensitivity of the target tissues of the developing external genitalia to androgens.
3. premature termination of androgen stimulation due to premature degeneration of fetal testicular mesenchymal cells cells. Other possible causes include inadequate synthesis of testosterone and dihydrotestosterone (defective or deficient 5α reductase), and defects in the quality and quantity of androgen receptors.
Typical clinical manifestations of suburethral cleft include the following.
1. Ectopic urethral orifice.
The urethral orifice may appear anywhere from the proximal end of the normal urethra to the perineal urethra. Some of the urethral orifices have strictures.
2.Downward curvature of the penis
The penis bends ventrally and has difficulty in sexual intercourse in adulthood.
3.Abnormal distribution of foreskin
The foreskin on the ventral side of the head of the penis fails to fuse in the midline, so it has a V-shaped defect, the foreskin tether is absent, and all the foreskin is transferred to the dorsal side of the head of the penis in a cap-like accumulation.
4.Other related abnormalities
Other associated anomalies include cryptorchidism (7-9%), inguinal hernia (about 12%) and syringomyelia (9-16%). The incidence of inguinal hernia is similar in patients with anterior, middle and posterior hypospadias, but cryptorchidism is more common in patients with posterior hypospadias. Male infants with both hypospadias and cryptorchidism should also be alerted to the need to evaluate for the possibility of hermaphroditism when the external genitalia are evident in time. Prostatic capsules occur in severe hypospadias and may be a remnant of incomplete degeneration of the paramedian duct or incomplete masculinization of the urogenital sinuses. Some patients may have combined scrotal transposition, penile torsion, micropenis and duplicated urethra, and in rare cases, anorectal malformations.
Diagnostic differential diagnosis.
Hypospadias can be diagnosed based on its typical clinical presentation. However, in cases of hypospadias combined with bilateral cryptorchidism, attention should be paid to the presence of gender abnormalities. Examination includes.
1.Physical examination: observation of the patient’s body shape, stature and the presence of secondary sexual characteristics, external genital examination for the presence of vagina, touching the texture and volume of bilateral testes.
2, examination of chromosomes.
3, urine 17 ketosteroid test.
4.Gonadal biopsy or laparoscopy.
Disease treatment.
There are more than 300 surgical options for hypospadias, but there is no one procedure that is satisfactorily accepted by the majority of urologists. The standard of cure for hypospadias is that the urethral orifice is located in the positive position of the head of the penis, the undercurvature of the penis is completely corrected, the appearance of the penis is close to normal, the ability to urinate standing up, and the ability to have a normal sexual life in adulthood. The surgery should be performed at 6-18 months of age to relieve the parents and the child of the mental stress. The choice of surgery is based on the presence or absence of combined penile hypospadias.
The treatment of hypospadias without penile hypospadias, or hypospadias can be corrected by tightening the dorsal white membrane of the penis without cutting the urethral plate.
1.Head of penis, coronal sulcus type: Urethral orifice anterior displacement and head of penis molding can be used. The advantage of this procedure is that the urethra is placed deeper in the head of penis, and the oval (slit-like) wide urethral orifice can be obtained, and the appearance of the urethral orifice is more satisfying, the main disadvantage of this technique is the urethral orifice posterior displacement and urethral stenosis.
2, coronal groove, subcoronal groove type and patients whose urethral orifice is located in the first 1/3 of the penile body: urethral base flap surgery can be used. This procedure can also be used for patients with failed suburethral cleft repair surgery.
3, penile body, penile root hypospadias: a covered island foreskin flap formation can be used.
Complications of hypospadias repair include bleeding/hematoma, urethral stricture, urethral skin fistula, urethral stricture, urethral diverticulum, incisional infection, impaired healing, and repair failure. When reoperation is required, complications such as urethral stricture, urethral skin fistula, and urethral stricture can be quickly repaired by choosing the proper timing of surgery. However, more serious complications such as partial or complete failure of the hypospadias repair require a larger reconstructive surgery. Sometimes even a complete repair is required if the best tissue and conditions are not available. Generally, complication surgery should not be performed within 6 months of the previous repair unless bleeding, infection, or debridement occurs and requires immediate reoperative exploration.
Health education care.
Treatment of hypospadias is complex, with a variety of surgical procedures, and individualized treatment plans should be adopted according to the individualized differences of the patient. The complexity of the procedure and the possibility of failure should not be ignored during treatment. Psychological interventions are also carried out, especially to adjust the patient’s sexual psychology and reduce the patient’s psychological pressure.