As mentioned above, the sutures start to dissolve about one month after surgery. They dissolve by having a chemical reaction. When this occurs, the penis may become red, swollen, and small yellow “pustules” may appear. This is all normal and will disappear within a week without leaving a trace. You do not need to contact us.

Photo: Small pustules during the absorption of sutures 3-4 weeks after surgery:

It takes one month for the wound to heal by 70% and 6 months to heal by 100%. This is why any further surgery should be planned earliest 6 months after the last surgery.

This means that we should avoid any trauma to the penis for one month, use 2 diapers or sport protection for one month. Also, swimming, bathing, and sports should be postponed for one month after surgery.

After one month, the wound is stable and the child can lead a completely normal life (please note other recommendations for adults).

However, complete healing takes about 6 months after surgery.

The new urethra is made of your son’s own skin and fascia with normal blood vessels. It will grow normally as your son grows.

Our standard protocol is that the parents send an e-mail one month after surgery to report how the healing of the operation is progressing. The first routine post-operative examination is 3 months after surgery by the operating surgeon. We recommend maintaining regular follow-ups after 1 year, then 2 years, and subsequently every 3 to 5 years until puberty.

My son had surgery for his hypospadias a few weeks ago. Everything looked very nice until the surgeon removed the catheter from his penis. I noticed that gradually less urine is coming out from the tip of the penis 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 recognize 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 weeks 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 appears 1–4 months after surgery. In about 5% of cases, fistula may appear years after surgery due to a reaction to suture materials remaining in the penis after the complete healing of the wound.

Fistula after an unsuccessful hypospadias repair:

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 the new narrow urethra again and reconstruct a wide new urethra to avoid the fistula from coming back.

Photos: Recurrent fistula due to stenosis after TIP repair, more urine comes out of fistula than through the tip:

“My son had surgery for his hypospadias a few weeks ago. Everything looked very nice until 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 result in a very narrow urethra which may cause straining of the child, pain, and even back pressure on the urinary bladder and kidney, leading to urinary tract infection.

It is normal that the urine stream will become somewhat narrower a week or two after removal of the 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.

Stenosis with narrow new urethra	Stenosis after TIP	Stenosis and Fistula after TIP

Mild stenosis may happen after successful hypospadias repair due to excess contraction during the 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.

“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 squeeze, some secretions come out. Is this bad, does this require surgery?”

The surgeon uses absorbable sutures during hypospadias repair (vicryl or PDS). These sutures start 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. They 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 involves excising the scar and using subcuticular thin suture material.

“My son had perineal hypospadias and had surgery and everything went very well and he had no problem at all after surgery. A few months later, I have noticed that there is a bulge in the penis when he passes urine and when I change the pamper, few urine drops come out which are turbid and smell bad. I went to my pediatrician who did an 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 we reconstruct is formed of skin (a thin wall) compared with the normal thick-walled urethra. As urine passes 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 the pampers, and a 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 make the urine turbid and smelly, and the urine analysis may show bacteria and pus cells, which gives the false impression that the child has a 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.

“My son had surgery for his hypospadias a few weeks ago. Everything looked very nice until the surgeon removed the catheter from his penis. After that, I noticed that the glans and the wound have 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).

Wound dehiscence requires further surgery, preferably by an experienced surgeon who needs to reconstruct a new, wide, and healthy urethra.

“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:

• The child had curved corpora that are not becoming straight by excising the hypoplastic tissue on the under surface of the penis (the banana is curved!). If the curvature is less than 15%, the child can lead a normal life as an adult and there is no need for further surgery.
• The surgeon did not remove the hypoplastic bands completely.
• The surgeon performed dorsal plication which was incomplete or the sutures cut through.
• The curvature is due to scar contraction during healing. In this case, further surgery to excise the scar is worthwhile.

“My son had hypospadias surgery a week ago and everything looked OK. However, I have noticed that when he woke up today, 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 leakage after surgery or if the child received a hit against the penis (usually when he is asleep).

The Hematoma usually disappears spontaneously without complications, and there is no need for surgery in most cases. If surgery is needed, it should be delayed for at least a few months after everything has settled down completely.

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.

About 95% of patients with hypospadias have incomplete prepuce (i.e., foreskin above and no foreskin below). Prof. Hadidi prefers to wait 6 months after hypospadias correction to make sure that everything has healed well without complications before operating on the foreskin.

• The first is to perform foreskin reconstruction. About 70% of parents in Germany, Austria, and Switzerland, and almost 90% of parents in Southern Europe (Spain, Italy, and Greece) prefer foreskin reconstruction. The other possibility is to perform circumcision. This is usually the case among Jews and Muslims and 30% of parents in Germany, Austria, and Switzerland.
• Either operation takes about 30 minutes. The complications are slightly higher after foreskin reconstruction. Each has advantages and disadvantages. The final decision has to be taken by the parents. During the second operation, Professor Hadidi examines the new urethra to ensure that it is wide enough with no complications and makes fine adjustment of the glans and meatus as well as the foreskin.

Foreskin reconstruction, end of operation, after distal hypospadias	2.5 months after operation
2.5 months after operation	6 months after operation

Circumcision, end of operation, 6 months after hypospadias surgery	Circumcision, 6 months after hypospadias surgery
Circumcision, one day after operation	3 months after circumcision after hypospadias repair

….because it interferes with healing. Secretions would accumulate between the foreskin and the glans. This does increase the chances of infection and failure of the repair.

Photo above: foreskin was reconstructed during hypospadias correction. By pulling back the foreskin, you can see that the opening of the meatus is still at the origin place.

Most surgeons perform circumcision during hypospadias repair. Prof. Hadidi prefers to leave it in case complications occur and the foreskin is needed to correct the complications.

There is not a lot of healthy tissue available for a successful correction	At the end of operation through Prof. Hadidi

It is very important to avoid retraction of the foreskin for at least one month after surgery. Otherwise, the whole operation could fail and the wound would disrupt completely. This must not be done by the parents nor by the pediatrician looking after the child later on.