What is the management for a 6-month-old male baby with hypospadias who experiences swelling of the foreskin when passing urine?

Management of Hypospadias in a 6-Month-Old Male with Foreskin Swelling During Urination

Surgical referral to a pediatric urologist is the recommended management for this 6-month-old male with hypospadias presenting with foreskin swelling during urination. 1, 2

Initial Assessment and Considerations

• The swelling of the foreskin during urination indicates urinary outflow obstruction related to the hypospadias, requiring prompt evaluation 2
• At 6 months of age, this child is at the optimal time for surgical intervention, as guidelines recommend hypospadias repair between 6 and 18 months of age 1, 3
• The child should not undergo circumcision, as the foreskin tissue may be needed for surgical reconstruction 4

Diagnostic Evaluation

• Determine the severity of hypospadias by assessing the position of the urethral meatus (distal, middle, or proximal) 2
• Evaluate for associated anomalies:
  • Examine for chordee (ventral curvature of the penis) which is more common in severe cases 2
  • Check for cryptorchidism (undescended testes) and inguinal hernia, which are the most common associated anomalies 2
  • If proximal hypospadias is present, especially with undescended testes, endocrinological evaluation is recommended to exclude disorders of sexual development 1, 5

Imaging Considerations

• Renal and bladder ultrasound should be performed to screen for urinary tract anomalies, particularly if the child has posterior (proximal) hypospadias 2
• In cases with moderate to severe hydronephrosis on ultrasound, a voiding cystourethrogram (VCUG) may be indicated to evaluate for vesicoureteral reflux and other urinary tract abnormalities 5
• VCUG is particularly important in males with suspected posterior urethral valves, which can present with similar symptoms 5

Surgical Management

• The ideal age for surgical repair is between 6 and 12 months of age in a healthy child 2, 6
• Surgical techniques depend on the severity of hypospadias:
  • For distal hypospadias (most common, ~70% of cases): preservation of the urethral plate and tubularization with or without midline incision is the most popular method 6
  • For proximal cases with severe curvature: a two-stage procedure may be preferable 6
• Postoperative care typically involves dripping-stent urinary drainage into a double diaper system 6

Expected Outcomes and Follow-up

• Complication rates vary by severity: less than 10% for primary distal repair and over 25% for staged procedures in proximal hypospadias 6
• Long-term follow-up is essential as complications can occur years after repair, including:
  • Lower urinary tract symptoms (occur twice as often in patients after hypospadias repair) 1
  • Potential issues with sexual function and cosmetic appearance 1, 3

Important Considerations for Parents

• Parents should be counseled about the condition, surgical options, and expected outcomes 6
• They should be informed that most cases can be repaired in a single operation on an outpatient basis 2
• Reassurance should be provided that even with less than perfect surgical results, most patients are able to enjoy satisfactory sexual and reproductive lives 2, 3