Hypospadias and Epispadia

HYPOSPADIAS AND EPISPADIA

PRESENTEDBY

RHODA EDONI-IDE

OUTLINE

DEFINITIONTYPES OF HYPOSPIDIASCAUSESSIGNS AND SYMPTOMSPATHOPHYSIOLOGY

OUTLINE

INVESTIGATIONNURSING RESPONSIBILITYTREATMENTCOMPLICATIONREFERENCES

HYPOSPADIAS

DEFINITION:• Hypospadias is a birth (congenital) defect in

which the opening of the urethra is on the underside of the penis.

• The urethra is the tube that drains urine from the bladder. In males, the opening of the urethra is normally at the end of the penis.

TYPES OF HYPOSPADIAS

1. ANTERIOR HYPOSPADIA

(70% of the cases) the meatus is located near the apex of the penis.

2.MEDIUM HYPOSPADIA

(10% of the cases) the meatus is located on the medium part of the penis, which often has a slight curvature.

CONT’D

• POSTERIOR HYPOSPADIA

(20% of the cases) these are the most severe types :

The meatus is located at the base of the penis or in the perineal scrotum. The penile curvature is considerable .

EPISPADIA

• A rare congenital defect that affects males and females in which the urethra opens on the top (dorsal) surface of the penis or vagina.

• An Epispadia is a rare type of malformation of the Penis or vagina in which the urethra ends in an opening on the upper aspect (the dorsum) of the penis or vagina.

CONT’D

• It can also develop in females when the urethra develops too far interiorly. It occurs around 1 in 120,000 male and 1 in 500,000 female births. ( Wikipedia 2012).

CONT’D

• Epispadia occurs in one of three forms.• The urethra may open on top of the head of

the penis; the entire urethra may be open to the full length of the penis, or the entire urethra may be open with the bladder opening on the abdominal wall. A similar condition can exist in females, but this is rare.

SIGNS &SYMPTOMS

1. Opening of the urethra below the tip on the bottom side of the penis.

2. Abnormal appearance of the glans penis (the tip) .

3. Incomplete foreskin in which the foreskin extends only around the top of the penis.

4. Curvature of the penis during an erection (called chordee) .

CONT’D

5. Buried penis.6. Abnormal position of scrotum with respect to

penis.

7.More severe forms of hypospadias occur when the opening is in the middle or base of the penis. Rarely, the opening is located in or behind the scrotum.

CAUSES

• The cause is often unknown.

• Sometimes, the condition is passed down through families.

• Hypospadias occurs in up to 4 in 1,000 newborn boys.

PATHOPHYSIOLOGY:

• Hypospadias and Epispadia are congenital defect that is thought to occur embryologically during urethral development, from 8-20 weeks' gestation.

• The external genital structures are identical in males and females until 8 weeks' gestation

CONT’D

The genitals develop a masculine phenotype in males primarily under the influence of testosterone.

As the phallus grows, the open urethral groove extends from its base to the level of the corona, ie the prominent posterior boarder of the glan penis.

• The classic theory is that the urethral folds coalesce in the midline from base to tip, forming a tabularized penile urethra and median scrotal raphae.

• This accounts for the posterior and middle urethra. The anterior or glandular urethra is thought to develop in a proximal direction,

CONT’D• With an ectodermal core forming at the tip of

the glans penis, which canalizes to join with the more proximal urethra at the level of the corona.

• The higher incidence of subcoronal hypospadias supports the vulnerable final step in this theory of development.

ASSESSMENT:

Upon examination, the foreskin is usually incomplete and the misplaced urethral opening is located.

• Hypospadias is typically diagnosed during a newborn examination. The opening of the urethra is below the tip of the penis.

CONT’D

• The penis may be curved and the foreskin not completely formed around the entire tip of the penis.

• Occasionally a specific type of hypospadias, known as mega meatus intact prepuce variant of hypospadias, isn't noted until a circumcision has been performed.

Diagnostic test

Prenatal ultrasound, but it usually occurs in males at birth. Mild hypospadias may not be diagnosed unless removal of the foreskin (circumcision) is performed.

Diagnosis of hypospadias in females requires thorough physical examination.

CONT’D

• This problem is almost always diagnosed soon after birth during a physical examination.

• Imaging tests may be done to look for other congenital defects which most times are not.

NURSING DIAGNOSIS

1. Discomfort/Pain r/t surgery

2. knowledge deficit r/t infertility

3. High risk for transmission of infection r/t STIs

4. Alteration in self esteem r/t nature of penis

SURGICAL TECHNIQUES:

• Mathieu's technique• Duckett's technique• Snodgrass's technique• Bracka's two-stage technique

TREATMENT

• The goal of surgical correction is to reconstruct a straight penis with a urethral opening as close to the tip of the penis as possible.

• Infants with hypospadias should not be circumcised. The foreskin should be kept for use in later surgical repair.

Surgery is usually done before the child starts school.

TREATMENT

• This will result in a properly directed urinary stream, straightened penis upon erection and an appearance similar to a circumcised penis.

NURSING MANAGEMENT

1. Assessment to change the perceived or actual feelings of the parents.

2. Record of urine output to probe reduction or sudden cessation of urine flow. Decrease in urine flow may indicate a sudden obstruction / dysfunction.

3.Observe and record the color of urine, the color of urine should be clear.

PRE OPERATIVE CARE

• Reassure patient’s parent/ caregiver.• Explain the condition to them.• Introduce them to other patients that have

done the surgery and are doing well if there is any.

• Answer all their questions correctly

and allay fear.• Make them sign a consent form.• Nil per oral.• Pre operative medications are

administered.• Monitor and record vital signs

POST OPERATIVE CARE

• Receive patient from the theatre noting the level of consciousness

• Observe the operation site for bleeding• Take vital signs• Adhere strictly to post operative

prescriptions/instructions.

CONT’D

• Use sterilize procedure technique to periodically monitor catheter, and to empty the content.

• Keep strict intake and output chart.

• Encourage increased fluid intake and maintain good hydration and urine flow.

• Advice mother/caregiver on discharge.

PROGNOSIS

• Results after surgery are most often good. In some cases, more surgery is needed to correct fistulas or a return of the abnormal penis curve.

• Most males can have normal adult sexual activity.

Complications

1.Undescended testicles and inguinal hernias (i.e., located in the groin).

2. Upper urinary tract anomalies .

3. Incontinence, Backflow of urine from the ureter to the

bladder (vesicoureteral reflux).

6. Sexual dysfunctionSexual intercourse may be difficult or impossible in

severe cases. erection difficulties and premature ejaculation have been reported in adulthood in patients who have had surgery for hypospadias in childhood.

5. Depression and psycho-social complications.

REFERENCES

1. Ryu J, Kim B. MR imaging of the male and female urethra. Radiographics. 21 (5): 1169-85.

2. Nelson, Waldo E., et al., editors. "Anomalies of the Bladder" In Nelson Textbook of Pediatrics. Philadelphia: W. B. Saunders, 2000, pp. 1639-1642.

3. Nelson, Waldo E., et al., editors. "Anomalies of the penis and urethra" In Nelson Textbook of Pediatrics. Philadelphia: W. B. Saunders, 2000, pp. 1645-1650.

• Marks; 8/10