Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 1 Distal Hypospadias, Treated or Untreated? A Case Report Agus Santosa* Universitas Muhammadiyah Purwokerto, Indonesia Corresponding author: agussantosa@ump.ac.id ABSTRACT Background: Treatment for distal hypospadias is a controversy among the experts. Some argue that it does not require any surgery if it does not interfere with the patient's urinary and sexuality. Purpose: This study aimed to determine whether patients with distal hypospadias need treated or untreated. Methods: The method used is a case study. Participants in this study is a 10-year-old male with distal hypospadias—location of the study in Purwokerto city, Banyumas district, Central Java. Participants were interviewed and physically examined by a doctor and nurse. The results of interviews and physical examinations are recorded and analyzed based on a literature review to determine the decision, treatment, or untreated. Results: A 10-year-old patient with hypospadias and the pediatric urologist do not give surgery advice, because the urethral opening is still close to the glans penis, and there are no symptoms of urinary dysfunction. Conclusion: Patients with distal hypospadias may be untreated as long as they do not interfere with urinary function. Keywords: Child, Hypospadias, Urologists, Sexuality, Reconstructive Surgical Procedures. Received April, 30, 2020; Revised June 6, 2020; Accepted July 28, 2020 DOI: https://doi.org/10.30994/jnp.v4i1.100 The Journal of Nursing Practice, its website, and the articles published there in are licensed under a Creative Commons Attribution- NonCommercial-ShareAlike 4.0 International License. mailto:agussantosa@ump.ac.id https://doi.org/10.30994/jnp.v4i1.100 Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 2 BACKGROUND Hypospadias is a congenital abnormality at birth, where the urethral opening's location is below the penis (Djakovic, Nyarangi-Dix, Ozturk, & Hohenfellner, 2008). Around 70% of hypospadias identified are the distal hypospadias (van der Horst & de Wall, 2017). The exact prevalence of hypospadias in the world is difficult to estimate. A study reported the prevalence of hypospadias in the word 20.9 per 10,000 live births (Yu et al., 2019). Distal hypospadias is often regarded as "normal function," and the surgery for improvement is still being debated. The goal of hypospadias reconstruction surgery is to improve penis appearance and the urinary function. The reconstruction surgery can be done at any age but is recommended to do in 6-18 months old. As seen as a reasonable condition, the parents usually do not think of any immediate operation; they will then fall to the thought as their child has grown up (Bhandarkar & Garriboli, 2019). Some opinions of pediatric urologist doctors also confirm that if the hypospadias is not expected to interfere with urination and sexual function, they do not need surgery. Surgery can be considered for cosmetic purposes. The surgery will require the bending of the penis and the presence of disrupting urinary function. It sometimes requires more than a stage. Besides, the artificial urethra can leak (fistula), or scar tissue can appear along the bottom of the penis. As a result, urine leakage can occur, thus needs an additional operation to repair it (Soebadi, 2015). OBJECTIVE This study aimed to determine whether patients with distal hypospadias need treated or untreated and what factors are based on a literature review. METHODS The method used is a case study. Participants in this study is a 10-year-old male with distal hypospadias—location of the study in Purwokerto city, Banyumas district, Central Java. Participants were interviewed and physically examined by a doctor and nurse. The results of interviews and physical examinations are recorded and analyzed based on a literature review to determine the decision, treatment, or untreated. RESULTS A 10-year-old child experienced Hypospadia. A surgical nurse's physical examination revealed that the urethral opening was not at the tip of the penis but the neck of the glans, indicating distal hypospadias (Figure 1). The appearance of the penis is hooded because only the upper half of the penis is covered by foreskin (prepuce). The patient has no complaints of pain or difficulty urinating, but he should lift his penis glans to urinate well. The parents are anxious about their children's future, whether their child will have healthy sexuality, and whether he can still have offspring(s). The patient advised visiting the pediatric urologist. The result of the examination shows that he has distal hypospadias. He was not advised to undergo hypospadias reconstruction surgery because the urethral opening is still close to the glans penis, and there are no symptoms of urinary dysfunction. Besides, the operations will mean expensive costs and maybe requires two stages of surgery. The doctor argued that his sexual function would be useful, and he would still be able to have children without any surgery performed. Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 3 DISCUSSION Hypospadias is a congenital abnormality at birth, where the location of the urethral opening is below the penis (Djakovic, Nyarangi-Dix, Ozturk, & Hohenfellner, 2008). Based on the position of the meatus, hypospadias divided into distal and proximal (van der Horst & de Wall, 2017). Hypospadias is very easy to detect because its symptoms are very typical. The symptoms are the opening of the urethra in locations other than the tip of the penis, the curve of the penis pointing downwards (chordee), appearance of the penis veil because the foreskin only includes the upper half of the penis, and the urination is not normal (Kraft, Shukla, & Canning, 2010). Hypospadias is a congenital disorder with multifactorial causes. The genetic factor, prenatally hormonal stimulation, placental, and environmental regarded to be hypospadias. As much as 7% of hypospadias patients have a genetic history (Fredell et al., 2002). The study found that patients with hypospadias had mutations in the genes of WT1, SF1, BMP4, BMP7, HOXA4, HOXB6, FGF8, FGFR2, AR, HSD3B2, SRD5A2, ATF3, MAMLD1, MID1, and BNC2 (van der Zanden et al., 2012). Lack of androgen hormone production, increased estrogen during pregnancy, and placental insufficiency regarded to be a factor in hypospadias (Hsieh, Breyer, Eisenberg, & Baskin, 2008; Sharpe, 2003; Yinon et al., 2010). Environmental variables such as exposure to pollution and chemicals can also increase the incidence of hypospadias (Bouty, Ayers, Pask, Heloury, & Sinclair, 2015). Purposeful consideration: Cosmetic or Reconstructive The only hypospadias treatment is reconstructive surgery (Djakovic, Nyarangi-Dix, Ozturk, & Hohenfellner, 2008). There are various reconstructive surgery techniques for hypospadias patients, and they have a success rate (Smith, 1953). Although the surgery need for distal hypospadias is still controversial among the pediatric urologists--whether it is cosmetic or reconstructive surgery--they agreed that surgery has to taken if it interferes with the patient's urinary process (Snodgrass & Bush, 2018). In the case in question, the pediatric urologist does not recommend surgery because the urethral opening is still close to the glans penis. Besides, the patient also does not complain of urinary difficulties or others. Thus, the pediatrician thinks that surgery on distal hypospadias is more cosmetic nature than reconstructive. Physiological considerations The hypospadias-affected penis will not develop normally. If the condition not treated, there will be more adverse symptoms. Among them are an abnormal shape of the penis, arduous sexual intercourse, dysuria, strangury, and even urinary incontinence. In such a situation, surgery will be urgently required (Keays et al., 2016; Schlomer, Breyer, Copp, Baskin, & DiSandro, 2014; Snodgrass & Bush, 2018). Consideration of complications The results of surgery for hypospadias patients are often unsatisfactory, with reported rates of complications reaching 40% and even more (Appeadu-Mensah et al., 2015; Mammo et al., 2018). For distal hypospadias, the highest complication reported reaching 33% (Klijn, Dik, & de Jong, 2001; Stein, 2012). Postoperative hypospadias complications are divided into mild and severe complications. Minor complications include bleeding, hematoma, edema, and severe complications, including wound infection, wound dehiscence, skin necrosis, flap necrosis, fistula, and penile torsion (Agrawal & Misra, 2013; Bhat & Mandal, Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 4 2008). Some experts could consider this in deciding either to do a repair operation or not. Cost considerations Hypospadias surgery can be performed in a single stage or multiple stages, depending on the method applied, with or without urethral reconstruction (Bracka, 2008; Stein, 2012; Subramaniam, Spinoit, & Hoebeke, 2011). One-stage surgery is a standard practice in the management of distal hypospadias (Badawy & Fahmy, 2013), but a study reports that its success rate is only 55.9% (Mammo et al., 2018). The surgery cost is around the US $ 14,000 (Svensson, Reychman, Troëng, & Åberg, 1997). In Indonesia, the range of its costs is between Rp. 30,000,000-80,000,000 (US $ 2,142-5,714), depending on the hospital rate. Consideration of sexual function and infertility A study conducted in adults with distal hypospadias who did not take surgery. It found that they were not interested in corrective surgery. They stated that they remained satisfied with the appearance of their penis, retained normal sexual function, and did not have any infertility problems (Dodds et al., 2008). Another survey result proved contradictory results for those having surgery. A patient with hypospadias who have undergone a surgery claimed dissatisfaction with the penis appearance and size. It also found a decrease in libido after hypospadias repair (Kimihiko et al., 2006). This is likely related to an unfortunate result of cosmetic surgery (Springer, A., 2014). A weak erection and ejaculation are experienced by almost all post-repair hypospadias patients (Singh, Jayanthi, & Gopalakrishnan, 2008). There were no infertility problems found in distal hypospadias, either treated or not (Kumar et al., 2016). The issues only found in those with the proximal type, and they usually have lower fertility (Ortqvist et al., 2017). CONCLUSION Patients with distal hypospadias may not be treated as long as it does not interfere with the patient's urinary function. They will have a healthy sex life and have children. The physiological aspect, postoperative complications, and cost factors are more relevant to decision treatment of distal hypospadias than the cosmetic issue. IMPLICATION FOR NURSING SCIENCE The role of the nurse as an educator is crucial in this case. Health education for patients and families is essential so that families and patients feel calm. CONFLICTS OF INTEREST The author declares no conflict of interest. Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 5 REFERENCES Agrawal, K., & Misra, A. (2013). Unfavourable results in hypospadias. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 46(2), 419–427. http://doi.org/10.4103/0970-0358.118623 Appeadu-Mensah, W., Hesse, A. A. J., Glover-Addy, H., Osei-Nketiah, S., Etwire, V., & Sarpong, P. A. (2015). Complications of hypospadias surgery: Experience in a tertiary hospital of a developing country. African Journal of Paediatric Surgery : AJPS, 12(4), 211–216. http://doi.org/10.4103/0189-6725.172538 Badawy, H., & Fahmy, A. (2013). Single- vs. multi-stage repair of proximal hypospadias: The dilemma continues. Arab Journal of Urology, 11(2), 174–181. http://doi.org/- 10.1016/j.aju.2013.03.009 Bhandarkar, K., & Garriboli, M. (2019). Repair of Distal Hypospadias : Cosmetic or Reconstructive ?, (April), 89–95. Retrieved from https://emj.emg-health.com/wp- content/uploads/sites/2/2019/04/Repair-of-Distal-Hypospadias....pdf Bhat, A., & Mandal, A. K. (2008). Acute postoperative complications of hypospadias repair. Indian Journal of Urology : IJU : Journal of the Urological Society of India, 24(2), 241–248. http://doi.org/10.4103/0970-1591.40622 Bouty, A., Ayers, K. L., Pask, A., Heloury, Y., & Sinclair, A. H. (2015). The Genetic and Environmental Factors Underlying Hypospadias. Sexual Development : Genetics, Molecular Biology, Evolution, Endocrinology, Embryology, and Pathology of Sex Determination and Differentiation, 9(5), 239–259. https://doi.org/10.1159/000- 441988 Bracka, A. (2008). The role of two-stage repair in modern hypospadiology. Indian Journal of Urology : IJU : Journal of the Urological Society of India, 24(2), 210–218. https://doi.org/10.4103/0970-1591.40618 Djakovic, N., Nyarangi-Dix, J., Ozturk, A., & Hohenfellner, M. (2008). Hypospadias. Advances in Urology, 2008, 650135. https://doi.org/10.1155/2008/650135 Dodds, P. R., Batter, S. J., Shield, D. E., Serels, S. R., Garafalo, F. A., & Maloney, P. K. (2008). Adaptation of adults to uncorrected hypospadias. Urology, 71(4), 682–685; discussion 685. https://doi.org/10.1016/j.urology.2007.07.078 Fredell, L., Kockum, I., Hansson, E., Holmner, S., Lundquist, L., Lackgren, G., … Nor- denskjold, A. (2002). Heredity of hypospadias and the significance of low birth we- ight. The Journal of Urology, 167(3), 1423–1427. https://doi.org/10.1016/S0022- 5347(05)65334-7 Hsieh, M. H., Breyer, B. N., Eisenberg, M. L., & Baskin, L. S. (2008). Associations among hypospadias, cryptorchidism, anogenital distance, and endocrine disruption. Current Urology Reports, 9(2), 137–142. https://doi.org/10.1007/s11934-008-002- 5-0 Keays, M. A., Starke, N., Lee, S. C., Bernstein, I., Snodgrass, W. T., & Bush, N. C. (2016). Patient Reported Outcomes in Preoperative and Postoperative Patients with Hypospadias. The Journal of Urology, 195(4 Pt 2), 1215–1220. https://doi.org/10.- 1016/j.juro.2015.11.066 Kimihiko, M., Hidehiro, K., Hiroshi, T., Tsuyoshi, F., Hiroshi, H., Hiroshi, S., … Katsuya, N. (2006). Long-Term Cosmetic and Sexual Outcome of Hypospadias Surgery: Norm Related Study in Adolescence. Journal of Urology, 176(4S), 1889–1893. https://doi.org/10.1016/S0022-5347(06)00600-8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3901923/ http://www.afrjpaedsurg.org/text.asp?2015/12/4/211/172538 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443004/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443004/ http://www.indianjurol.com/article.asp?issn=0970-1591;year=2008;volume=24;issue=2;spage=241;epage=248;aulast=Bhat https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012964/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012964/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684286/ https://www.hindawi.com/journals/au/2008/650135/ https://pubmed.ncbi.nlm.nih.gov/18279924/ https://www.auajournals.org/doi/pdf/10.1016/S0022-5347%2805%2965334-7 https://www.auajournals.org/doi/pdf/10.1016/S0022-5347%2805%2965334-7 https://link.springer.com/article/10.1007/s11934-008-0025-0 https://link.springer.com/article/10.1007/s11934-008-0025-0 https://pubmed.ncbi.nlm.nih.gov/26926541/ https://pubmed.ncbi.nlm.nih.gov/26926541/ https://pubmed.ncbi.nlm.nih.gov/26201846/ Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 6 Klijn, A. J., Dik, P., & de Jong, T. P. (2001). Results of preputial reconstruction in 77 boys with distal hypospadias. The Journal of Urology, 165(4), 1255–1257. Kraft, K. H., Shukla, A. R., & Canning, D. A. (2010). Hypospadias. The Urologic Clinics of North America, 37(2), 167–181. https://doi.org/10.1016/j.ucl.2010.03.003 Kumar, S., Tomar, V., Yadav, S. S., Priyadarshi, S., Vyas, N., & Agarwal, N. (2016). Fertility Potential in Adult Hypospadias. Journal of Clinical and Diagnostic Rese- arch : JCDR, 10(8), PC01-PC5. https://doi.org/10.7860/JCDR/2016/21307.8276 Mammo, T. N., Negash, S. A., Negussie, T., Getachew, H., Dejene, B., Tadesse, A., & Derbew, M. (2018). Hypospadias Repair in Ethiopia: A Five Year Review. Ethiopi- an Journal of Health Sciences, 28(6), 735–740. https://doi.org/10.4314/ejhs.- v28i6.8 Ortqvist, L., Fossum, M., Andersson, M., Nordenstrom, A., Frisen, L., Holmdahl, G., & Nordenskjold, A. (2017). Sexuality and fertility in men with hypospadias; impro- ved outcome. Andrology, 5(2), 286–293. https://doi.org/10.1111/andr.12309 Schlomer, B., Breyer, B., Copp, H., Baskin, L., & DiSandro, M. (2014). Do adult men with untreated hypospadias have adverse outcomes? A pilot study using a social media advertised survey. Journal of Pediatric Urology, 10(4), 672–679. https://- doi.org/10.1016/j.jpurol.2014.01.024 Sharpe, R. M. (2003). The ’oestrogen hypothesis’- where do we stand now? International Journal of Andrology, 26(1), 2–15. https://doi.org/10.1046/j.1365-2605.2003.00- 367.x Singh, J. C., Jayanthi, V. R., & Gopalakrishnan, G. (2008). Effect of hypospadias on sexual function and reproduction. Indian Journal of Urology : IJU : Journal of the Urological Society of India, 24(2), 249–252. https://doi.org/10.4103/0970- 1591.40623 Smith, D. R. (1953). The treatment of hypospadias. California Medicine, 78(2), 95–100. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/13019602 Snodgrass, W., & Bush, N. (2018, August). Is distal hypospadias repair mostly a cosmetic operation? Journal of Pediatric Urology. England. https://doi.org/10.1016/j.jpur- ol.2018.06.004 Soebadi, A. (2015). Agar Bisa Kembali Normal, Operasi Diperlukan untuk Atasi Hipospa- dia. DetikHealth. Retrieved from https://health.detik.com/ibu-dan-anak/d-279563- 3/agar-bisa-kembali-normal-operasi-diperlukan-untuk-atasi-hipospadia Springer, A. (2014). Assessment of Outcome in Hypospadias Surgery – A Review. Fron- tiers in Pediatrics. doi: 10.3389/fped.2014.00002 Stein, R. (2012). Hypospadias. European Urology Supplements, 11(2), 33–45. https://do- i.org/10.1016/j.eursup.2012.01.002 Subramaniam, R., Spinoit, A. F., & Hoebeke, P. (2011). Hypospadias repair: an overview of the actual techniques. Seminars in Plastic Surgery, 25(3), 206–212. https://doi.- org/10.1055/s-0031-1281490 Svensson, H., Reychman, M., Troëng, T., & Åberg, M. (1997). Staged Reconstruction of Hypospadias with Chordee: Outcome and Costs. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 31(1), 51–55. https://doi.org/10.- 3109/02844319709010505 van der Horst, H. J. R., & de Wall, L. L. (2017). Hypospadias, all there is to know. Euro- pean Journal of Pediatrics, 176(4), 435–441. https://doi.org/10.1007/s00431-017- 2864-5 https://pubmed.ncbi.nlm.nih.gov/20569796/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5028481/ https://pubmed.ncbi.nlm.nih.gov/30607090/ https://pubmed.ncbi.nlm.nih.gov/30607090/ https://pubmed.ncbi.nlm.nih.gov/27992969/ https://pubmed.ncbi.nlm.nih.gov/24613143/ https://pubmed.ncbi.nlm.nih.gov/24613143/ https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2605.2003.00367.x https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2605.2003.00367.x http://www.indianjurol.com/article.asp?issn=0970-1591;year=2008;volume=24;issue=2;spage=249;epage=252;aulast=Singh http://www.indianjurol.com/article.asp?issn=0970-1591;year=2008;volume=24;issue=2;spage=249;epage=252;aulast=Singh https://pubmed.ncbi.nlm.nih.gov/13019602/ https://pubmed.ncbi.nlm.nih.gov/24479107/ https://www.eu-openscience.europeanurology.com/article/S1569-9056(12)00003-6/fulltext https://www.eu-openscience.europeanurology.com/article/S1569-9056(12)00003-6/fulltext https://www.researchgate.net/publication/224767256_Hypospadias_Repair_An_Overview_of_the_Actual_Techniques https://www.researchgate.net/publication/224767256_Hypospadias_Repair_An_Overview_of_the_Actual_Techniques https://europepmc.org/article/med/9075288 https://europepmc.org/article/med/9075288 https://link.springer.com/article/10.1007/s00431-017-2864-5 https://link.springer.com/article/10.1007/s00431-017-2864-5 Journal Of Nursing Practice http://thejnp.org ISSN: 2614-3488 (print); 2614-3496 (online) Vol.4 No.1. October 2020. Page.1-7 7 van der Zanden, L. F. M., van Rooij, I. A. L. M., Feitz, W. F. J., Franke, B., Knoers, N. V. A. M., & Roeleveld, N. (2012). Aetiology of hypospadias: a systematic review of genes and environment. Human Reproduction Update, 18(3), 260–283. https://doi.- org/10.1093/humupd/dms002 Yinon, Y., Kingdom, J. C. P., Proctor, L. K., Kelly, E. N., Salle, J. L. P., Wherrett, D., … Chitayat, D. (2010). Hypospadias in males with intrauterine growth restriction due to placental insufficiency: the placental role in the embryogenesis of male external genitalia. American Journal of Medical Genetics. Part A, 152A(1), 75–83. https://doi.org/10.1002/ajmg.a.33140 Yu, X., Nassar, N., Mastroiacovo, P., Canfield, M., Groisman, B., Bermejo-Sánchez, E., … Agopian, A. J. (2019). Hypospadias Prevalence and Trends in International Birth Defect Surveillance Systems, 1980–2010. European Urology, 76(4), 482–490. https://doi.org/10.1016/j.eururo.2019.06.027 FIGURE CAPTIONS Figure 1. Distal hypospadias appear https://pubmed.ncbi.nlm.nih.gov/22371315/ https://pubmed.ncbi.nlm.nih.gov/22371315/ https://pubmed.ncbi.nlm.nih.gov/20014131/ https://pubmed.ncbi.nlm.nih.gov/31300237/