50. What is a fistula, does this require surgical correction?
"My son had surgery for his hypospadias few weeks ago. Everything looked very nice untill the surgeon removed the catheter from his penis. I noticed that gradually less urine is coming out from the tip of the pensi and urine is coming out from another opening near where the original urine opening was. What is this ? Is this a fistula?"
Fistula is a tract or tunnel connecting between the urethra and the skin. Through this tunnel, urine comes out. The parents can recognise this easily when they see that urine comes out through more than one opening when the child is passing urine more than a month after surgery. During the first month after surgery, the wound has not healed and it is normal that urine may come out in between the sutures. The fistula may be single or multiple ( the parents may notice more than two streams of urine). The fistula normally appear1 - 4 months after surgery. In about 5 % of cases. Fistula may appear years after surgery due to reaction to suture materials remaining in the penis after complete healing of wound.
Fistula after hypospadias repair:
51. My son developed a fistula after surgery. Does this mean that the operation was not successful? Does my son need to have the whole operation done again? How can we increase the chances of success after the second surgery? Can it come back after surgery and why?
Fistula is a well known complication after hypospadias repair. The fistula may recur after surgical closure, (especially after TIP repair) if the new urethra is narrow.
In most cases after TIP repair, it is usually necessary to open all new narrow urethra again and reconstruct a wide new urethra to avoid that the fistula may come back.
Recurrent fistula due to stenosis after TIP repair, More urine comes out of fistula than thruough the tip:
52. What does a “Stenosis” mean, does this require surgical correction?
My son had surgery for his hypospadias few weeks ago. Everything looked very nice untill the surgeon removed the catheter from his penis. At the beginning, the urine stream was very good from the tip of the penis. Gradually, the urine stream became narrower and my son starts to strain and has severe pain when he passes urine?
Stenosis after hypospadias repair means narrowing of the meatus or new urethra. Contraction of the wound (particularly with circular suture line) is a normal process of healing. However, if it is excessive or the newly reconstructed urethra is narrow, further contraction of the wound would recult in a very narrow urethra which may cause straining of the child, pain and even back pressure on the urinary bladder and kidney and urinary tract infection.
It is normal that the urine stream will become somewhat narrower a week or two after removal of catheter. However, if the urine stream is very narrow and long and the child is having pain or severe straining, the parents should seek medical advice.
53. Dilatation: "My son developed “Stenosis” after hypospadias surgery, does dilatation cures the problem? The operating surgeon performed dilatation several times but about 2 weeks after each dilatation, it becomes narrow again why?"
Mild stenosis may happen after successful hypospadias repair due to excess contraction during healing process. However, if stenosis recurs after more than 2 dilatations, this means that dilatation is not helpful and that the new urethra is actually narrow and further surgery may be needed.
54. What are “Suture Tracts”, does it differ from fistula? Does this require surgical correction?
"My son had hypospadias surgery and everything went very well and he has no problems at all. I have noticed that there are black points near the midline where the incision was and when you squeze some secretions come out. Is this bad, does this require surgery?"
The surgeon uses absorbable sutures during hypospadias repair (vicryl or PDS). These sutures sutures atart to disappear 3-4 weeks after surgery. During this period, epithelium may grow around the sutures and form a small tunnel that is not connected to the urethra and therefore, no urine comes out of these small tunnels. With complete healing the sutures will disappear completely but those “Suture Tracts” or tiny tunnels will remain because of the epithelium. It appear as small black points where the sutures were. It is not harmful and does not require surgery unless from the cosmetic point of view it is bothering the patient or his parents. Surgery is simple and means simple excision of the scar and using subcuticular thin suture material.
photo of suture tracts
55. What is a “Diverticulum” or a pocket, does this require surgical correction?
"My son had perineal hypospadias and had surgery and everything went very well and he had no problem at all after surgery. Few months later, I have noticed that there is bulge in the penis when he passes urine and when I change the pamper, few urine drops come out which are turbid and smells bad. I went to my pediatrician who did examination of urine and it showed pus cells, bacteria in urine. What is that? Is my son incontinent for urine? Can this be corrected?"
A “Diverticulum” or a “pocket” is a well known complication that may occur after proximal hypospadias (Grade IIIb or Grade IV) or when there is a distal obstruction. The possible explanation is that the new urethra that we reconstruct is formed of skin (thin wall) as compared with the normal thick walled normal urethra. As urine pass through the proximal urethra, there may be dilatation resulting in the formation of a pocket or diverticulum.
Clinically, this presents with bulging of the penis when the child passes urine. Also, the urine staying in the pouch comes out when the mother presses on the penis while changing pampers and few urine drops come out. This may give the false impression that the child is incontinent.
The other thing is as urine remains in the pouch, bacteria accumulate and makes the urine turbid and smelly and the urine analysis may show bacteria and pus cells which gives the false impression that the child has urinary tract infection. This is not true as the infected urine exists only in the pouch and not inside the body.
If the pocket is small and not causing symptoms, the mother may empty it every time she changes the pampers and the child may grow out of it with time.
If the pouch is big and causing symptoms, this should be removed surgically.
56. What is a “wound dehiscence”, does this require surgical correction?
"My son had surgery for his hypospadias few weeks ago. Everything looked very nice untill the surgeon removed the catheter from his penis. After that I noticed that the glans and the wound has gradually opened and now my son is passing urine just below the glans, near where the original urine opening was before surgery. Does this mean that the operation was not successful? Does my son need to have the whole operation done again? How can we increase the chances of success after the second surgery?"
“Wound dehiscence” means that the wound has opened. It may be partial affecting the glans only or the whole wound and in that case the urine will come out from the original opening as if the child did not have surgery. This may occur in case of severe wound infection or if the new urethra is narrow (e.g. after the TIP procedure).
"My son had hypospadias surgery and he is passing urine from the tip of the penis. However, I have noticed that the penis is still curved. Is this bad? Does this affect him in the future? Does he need further surgery? Can this be improved?
Chordee (penile curvature) may recur or persist after hypospadias surgery. There are several possible causes:
"My son had hypospadias surgery a week ago and everything looked OK.However, I have noticed that when he woke up today that the base of the penis and the scrotum is blue, green. Is this bad? Does he need further surgery? Can this be improved?"
A “Haematoma” is a collection of blood which may be red, blue or green (depending on the degree of absorption. This may occur if there was some blood leak after surgery or if the child received a hit against the penis (usually when he is asleep).
The “Hematoma” usually disappears spontaneously without complication and there is no need for surgery in most cases. If surgery is needed, this should be delayed at least for few months after everything has settled down completely.
59. Can Hypospadias Surgery cause urine incontinence or bed wetting at night?
Hypospadias always involves the urethra distal (after) the level of the sphincter (valve) that controls urine continence. So, hypospadias surgery should never cause urine incontinence or bed wetting at night.
copyright Prof. Hadidi 2012