I.

Introduction:

Hypospadias is a birth defect of the urethra in the male that

involves an abnormally placed urinary meatus (opening). Instead of
opening at the tip of the glans of the penis, a hypospadic urethra
opens anywhere along a line (the urethral groove) running from the tip
along the underside (ventral aspect) of the shaft to the junction of the
penis and scrotum or perineum. A distal hypospadias may be
suspected even in an uncircumcised boy from an abnormally formed
foreskin and downward tilt of the glans.
The urethral meatus opens on the glans penis in about 50-75% of
cases; these are categorized as first degree hypospadias. Second
degree (when the urethra opens on the shaft), and third degree (when
the urethra opens on the perineum) occur in up to 20 and 30% of cases
respectively. The more severe degrees are more likely to be associated
with chordee, in which the phallus is incompletely separated from the
perineum or is still tethered downwards by connective tissue, or with
undescended testes (cryptorchidism).
Hypospadias are among the most common birth defects of the male
genitalia (second to cryptorchidism), but widely varying incidences
have been reported from different countries, from as low as 1 in 4000
to as high as 1 in 125 boys.
There has been some evidence that the incidence of hypospadias
around the world has been increasing in recent decades. In the United
States, two surveillance studies reported that the incidence had
increased from about 1 in 500 total births (1 in 250 boys) in the 1970s
to 1 in 250 total births (1 in 125 boys) in the 1990s. Although a slight
worldwide increase in hypospadias was reported in the 1980s, studies
in different countries and regions have yielded conflicting results and
some registries have reported decreases.
First degree hypospadias are primarily a cosmetic defect and
have little effect on function except for direction of the urinary stream.
If uncorrected, a second or third degree hypospadias can make male
urination messy, necessitate that it be performed sitting, impair
delivery of semen into the vagina (possibly creating problems with
fertility), or interfere with erections. In developed countries, most
hypospadias are surgically repaired in infancy. Surgical repair of first
and second degree hypospadias is nearly always successful in one
procedure, usually performed in the first year of life by a pediatric
urologist or a plastic surgeon. When the hypospadias is third degree, or
there are associated birth defects such as chordee or cryptorchidism,
the best management can be a more complicated decision. A

karyotype and endocrine evaluation should be performed to detect

intersex conditions or hormone deficiencies. If the penis is small,
testosterone or human chorionic gonadotropin (hCG) injections may be
given to enlarge it prior to surgery.
2
Surgical repair of severe hypospadias may require multiple
procedures and mucosal grafting. Preputial skin is often used for
grafting and circumcision should be avoided prior to repair. In a
minority of patients with severe hypospadias surgery produces
unsatisfactory results, such as scarring, curvature, or formation of
urethral fistulas, diverticula, or strictures. A fistula is an unwanted
opening through the skin along the course of the urethra, and can
result in urinary leakage or an abnormal stream. A diverticulum is an
"outpocketing" of the lining of the urethra which interferes with urinary
flow and may result in post-urination leakage. A stricture is a narrowing
of the urethra severe enough to obstruct flow. Reduced complication
rates even for third degree repair (e.g., fistula rates below 5%) have
been reported in recent years from centers with the most experience,
and surgical repair is now performed for the vast majority of infants
with hypospadias.
Because of the difficulties and lower success rates of surgical
repair of the most severe degrees of under virilization, some of these
genetically male but severely undervirilized infants have been
assigned and raised as girls, with feminizing surgical reconstruction.
Opinion has shifted against this approach in the last decade because
adult sexual function as a female has often been poor, and
development of a male gender identity despite female sex assignment
and rearing, has occurred in some XY children after reassignment for a
more severe type of genital birth defect, cloacal exstrophy.
Mild hypospadias most often occurs as an isolated birth defect
without detectable abnormality of the remainder of the reproductive or
endocrine system. However, a minority of infants, especially those with
more severe degrees of hypospadias will have additional structural
anomalies of the genitourinary tract. Up to 10% of boys with
hypospadias have at least one undescended testis, and a similar
number have an inguinal hernia. An enlarged prostatic utricle is
common when the hypospadias is severe (scrotal or perineal), and can
predispose to urinary tract infections, pseudo-incontinence, or even
stone formation.

II.

Patient Profile:

A. General Data:
Name: Schnider Sarvida
Age: 8 years old
Birthplace: Mandaue, Cebu
Sex: Male
Religion: Roman Catholic
Civil Status: Child
Address: Mandaue, Cebu City
Date Admitted: April 18, 2009
Time Admitted: 1:00pm
Attending Physician: Dr. Lim

B. Chief Complaint:
The patient was admitted at AMOSUP - Seamens Hospital Cebu last
April 18,2009 at 1:00pm in the afternoon due to the doctors advice of
having a scheduled operation. He was attended at the Emergency
department and had taken a clinical history and physical assessment.
He was transferred at the Pediatric Ward. He was attended by Dr.
Edwin Lim, a resident physician of the said hospital.

C. History of Present Illness:

Patients condition started when her mother notice that when his child
urinates the opening the urethral meatus is located underside of the
penis. The mother discovered that his son is born with congenital
defects of hypospadia, and seek for medical assistance.

4
D. Developmental task:

Havighurst:
Childhood(6-12)

1) Learning to physical skills necessary for

ordinary games: To learn the physical skills
that are necessary for the games and
physical activities that are highly valued in
childhood--such skills as throwing and
catching, kicking, tumbling, swimming, and
handling simple tools.
2) Building wholesome attitudes towards
oneself as a growing organism: To develop
habits of care of the body, of cleanliness
and safety, consistent with a wholesome,
realistic attitude which includes a sense of
physical normality and adequacy, the ability
to enjoy using the body, and a wholesome
attitude toward sex. Sex education should
be a matter of agreement between school
and parents, with the school doing what the
parents feel they cannot do so well. The
facts about animal and human reproduction
should be taught before puberty.
3) Learning to get along with age-mates: To
learn the give-and-take of social life among
peers. To learn to make friends and to get
along with enemies. To develop a "social
personality."
4) Learning an appropriate masculin or
feminine social role: To learn to be a boy or
a girl--to act the role that is expected and
rewarded. The sex role is taught so
vigorously by so many agencies that the
school probably has little more than a
remedial function, which is to assist boys
and girls who are having difficulty with the
task.
5) Developing fundamental skills reading,

writing, and calculating: To learn to read,

write, and calculate well enough to get
along in society.
6) Developing concepts necessary for
everyday living: A concept is an idea which
stands for a large number of particular
sense perceptions, or which stands for a
number of ideas of lesser degrees of
abstraction. The task is to acquire a store of
concepts sufficient for thinking effectively
about ordinary occupational, civic, and
social matters.
7) Developing conscience, morality, and a
scale of values: To develop an inner moral
control, respect for moral rules, and the
beginning of a rational scale of values.
Morality, or respect for rules of behavior, is
imposed on the child first by the parents.
Later, according to Piaget, the child learns
that rules are necessary and useful to the
conduct of any social enterprise, from
games to government, and thus learns a
"morality of cooperation or agreement"
which is a true moral autonomy and
necessary in a modern democratic society.
8) Achieving personal independence: To
become an autonomous person, able to
make plans and to act in the present and
immediate future independently of one's
parents and other adults. The young child
has become physically independent of his
parents but remains emotionally dependent
on them.
9) Developing attitudes toward social groups
and institutions: To develop social attitudes
that are basically democratic. Attitudes, or
emotionalized dispositions to act, are
learned mainly in three ways; (1) by
imitation of people with prestige in the eyes
of the learner; (2) by collection and
combination of pleasant or unpleasant
experiences associated with a given object
or situation; (3) by a single deeply

emotional experience--pleasant or
unpleasant--associated with a given object
or situation.

Erikson
School Age: 6 to 12 Years

Ego Development Outcome:

-Industry vs. Inferiority
Freudian psycho- sexual stages:
-Latency
Latency Stage - Sexual dormancy or
repression. The focus is on learning, skills,
schoolwork. This is actually not a
psychosexual stage because basically
normally nothing formative happens
sexually. Experiences, fears and
conditioning from the previous stages have
already shaped many of the child's feelings
and attitudes and these will re-surface in
the next stage.
Basic Strengths:
Method and Competence
During this stage, often called the Latency,
we are capable of learning, creating and
accomplishing numerous new skills and
knowledge, thus developing a sense of
industry. This is also a very social stage of
development and if we experience
unresolved feelings of inadequacy and
inferiority among our peers, we can have
serious problems in terms of competence

and self-esteem.
As the world expands a bit, our most
significant relationship is with the school
and neighborhood. Parents are no longer
the complete authorities they once were,
although they are still important.

7
E. Functional health patterns:

Health perception- Health Management

The patient have completed his immunization. Hes been

hospitalized for 3 times due to fever, LBM and tonsillitis. No known
allergies to any foods and drugs. Does not experience any accidents.
For him, being healthy is important. A person is healthy when he is
strong, he can do what she wants and does not experience any
diseases. He does his regular medical and dental check-ups. When he
is experiencing something wrong in her body, he tell it promptly to her
mother. He plays a lot and joins so sports activities. The patient is
healthy. He takes a bath once a day and brushes his teeth three times
a day. He does use lotion, shampoo and soap. He washes his hands
regularly but not always using soap. Health for him is important for
proper functioning. He wears slippers while inside their house. He feels
that his hygienic practices are adequate, and he feels clean and neat.

Nutritional Metabolic Pattern

He loves to eat pork, fish and vegetables. He is not choosy when it

comes to any cook and kind of food. He eats 3x a day. He eats junk
foods. He drinks 5 glasses of water a day. He takes his Vitamins.
During snack time, he usually eats banana because it is affordable and
readily available in their place. He eats food given by the hospital.

Elimination
He defecates twice a day. According to his the characteristic of hir stool
is hard, dry and colored brown. He urinates 4x a day and does not feel
any pain and difficulty.

Activity and Exercise

He joined many sports activities and schools. And does watch TV and
plays his PSP all the time. He always reads books and sometimes helps
his mom doing the household chores.

Cognitive-perceptual
The patient is going grade 3 this coming June. He has many awards. He
can read and write properly. He is aware to different people or
happening around him. He can talk properly. During the interview his
voice is weak. There are no any blockages of communication noted. He

does not have any difficulty when it comes to communication

Coping-stress

Whenever he has problem, he asks guidance from our Lord and his
parents He watches television and plays PSP as his stress
management. When he gets mad, he just keep quiet.

Value-belief

He is a Roman Catholic. He attends mass every Sunday. He always ask

the guidance of our Lord. Does always pray the rosary. He respects and
obeys his parents. For him education is very important to him, so he
strives hard to reach his goal.

9
F. Physical examination:
Skin, Hair and Nail

Evenly distributed with no patches

of hair loss; thick hair; nail are
short and clean. Has an intact
skin; has equal warmth on both
sides. No masses

Head, neck and lymph nodes

Rounded(normocephalic); smooth
skull contour, Has no tenderness;
no masses nor nodules

Mouth, Nose and sinus

Symmetric and straight; Uniform

color with nasal flaring, Nasal
septum intact and in midline.
Sinuses are not painful when
palpated. Pink in color, dry and
cracked lips

Eyes and Ears

Symmetrical and aligned with

each other; black; evenly
distributed. Movements are
symmetrical. Able to close the
eyes and has the ability to blink.
Ears: Same color as the facial skin;
tip of auricle aligned at the outer
canthus of the eye. Can hear
normal volume tones or words.

Thoracic and Lungs

Cardiovascular

no difficulty of breathing
Has full and rapid pulsation. 84
bpm.
Has a symmetrical abdominal
contour. Abdominal movements
noted when inhaling.

Abdomen

Reproductive
Musculoskeletal

Opening of the urethral meatus is

o the underside of the penis.
Proportionate to the body; even in
both sides. Extremities: No edema,
no pain when moved.

10
G. Cranial nerves:
Cranial nerves:
Cranial Nerve I (Olfactory):

identifies common odors

Cranial Nerve II (Optic):

not assessed

Cranial Nerve III

(Oculomotor) Cranial Nerve
IV (Trochlear) and Cranial
Nerve VI (Abducens):
Cranial Nerve V (Trigeminal)
Motor:

paired eye movement. PERRLA

Cranial Nerve VII (Facial):

good motor function

good sensation of cheeks and

forehead

 Cranial Nerve VIII (Acoustic

or Vestibulocochlear):
Cranial Nerve IX
(Glossopharyngeal) and X
(Vagus) Motor:
Cranial Nerve XI (Spinal
Accessory):
Cranial Nerve XII
(Hypoglossal):

not assessed
gag reflex present
good Rom of neck, and extremities
tongue at midline

H. Diagnostic and Laboratory Test:

-No labs found. Only Physical Examination they based the condition.

III.

11

Anatomy:
Male reproductive system (human)

The purpose of the organs of the male

reproductive system is to perform the
following functions:
-To produce, maintain
and transport sperm

(the male reproductive cells) and protective fluid

(semen)
-To discharge sperm within the female
reproductive tract during sex
-To produce and secrete male sex hormones
responsible for maintaining the male reproductive
system.

12
Penis

The penis has a long shaft and

enlarged tip called the glans penis.
The penis is the male copulatory
organ. When the male becomes
sexually aroused, the penis
becomes erect and ready for
sexual intercourse. Erection is
achieved because blood sinuses
within the erectile tissue of the
penis become filled with blood.
The arteries of the penis are
dilated while the veins are
passively compressed so that

blood flows into the erectile

cartilage under pressure. The male
penis is made of two different
tissues, and soft spongy tissue.
Cartilage is not in the penis.
The testes hang outside the
abdominal cavity of the male
within the scrotum. They begin
their development in the
abdominal cavity but descend into
the scrotal sacs during the last 2
months of fetal development. This
is required for the production of
sperm because internal body
temperatures are too high to
produce viable sperm.
This is the loose pouch-like sac of
skin that hangs behind the penis.
It contains the testicles (also
called testes), as well as many
nerves and blood vessels. The
scrotum acts as a "climate control
system" for the testes. For normal
sperm development, the testes
must be at a temperature slightly
cooler than body temperature.
Special muscles in the wall of the
scrotum allow it to contract and
relax, moving the testicles closer
to the body for warmth or farther
away from the body to cool the
temperature.

Testicles

Scrotum

13

IV.

Pathophysiology

The penis begins to form at approximately the fifth fetal week

under the influence of testosterone. The urethral folds start to fuse
over the urethral groove, and by the 14th week the process is
complete . A short in growth from the tip of the glans progresses

inward to meet the urethral tube at the fossa navicularis. The prepuce
is then formed at the end of the development process.
Hypospadias occurs when the fusion of the urethral folds stops
proximal to the tip of the glans penis and can occur anywhere along
the urethral groove.
Severe forms of hypospadias are accompanied by shortening of
the urethral groove, which causes ventral tethering of the penis, a
condition termed "chordee."
Hypospadias

Pills or
hormonal
medications

Some causes

Some causes

Cause is
unknown

Familie
s

Penis

Urethral opening

Glandular

Penile

Penoscrotal

Penineal

s/s:
Opening of the urethra below the tip on the bottom side of the penis
Abnormal appearance of the glans penis (the tip)
Incomplete foreskin in which the foreskin extends only around the top of the penis
Curvature of the penis during an erection (called chordee)
Buried penis
Abnormal position of scrotum with respect to penis

14

V.

Signs and Symptoms

Hypospadias are deformities of the penis resulting from incomplete

development of the urethra, the tube that carries urine from the
bladder to the penis. It can occur in many different ways, including

Opening of the urethra below the tip on the

bottom side of the penis
Abnormal appearance of the glans penis (the tip)
Incomplete foreskin in which the foreskin extends
only around the top of the penis
Curvature of the penis during an erection (called
chordee)
Buried penis
Abnormal position of scrotum with respect to
penis.

VI.

Medical and Nursing management:

Medical management
Treatment is by repair of
hypospadias. The surgery is
usually performed under general
anesthesia, which means that the
child is put to sleep with
medications. There are many
techniques for hypospadias repair.
Newer methods accomplish the
repair in one stage. The repair
procedure is fairly simple when
the opening is near the head of
the penis. The operation is more
complex when the urethral
opening is along the penile shaft.
In these cases, tissue flaps or skin
grafts may need to be
transplanted from other sites. A
urinary catheter, or a narrow tube
called a stent, is put in place for a
short period of time to keep the
urethra opened

Nursing management
It is important to address parents
concerns at the time of birth.
Preoperative teaching can relieve
some of their anxiety
about the future appearance and
functioning of the penis.
Postoperative care focuses on
protecting the surgical site from
injury. The infant or child returns
from surgery with the penis
wrapped in a simple dressing, and
sometimes a urethral stent (a
device used to maintain patency
of the urethral canal) is placed to
keep the new urethral canal open.
Plan care to ensure that the stent
does not get removed. Refer to the
hospitals policy for the
appropriate
use of physical restraints in this
situation.
Encourage fluid intake to maintain
adequate urinary output and
patency of the stent. Hourly
documentation of intake and
output is essential. Notify the
physician if there is
no urine drainage for 1 hour as
this may indicate obstruction. Pain
may be associated with bladder
spasms. Antibiotics are often

prescribed until the urinary stent

falls out. Discharge
teaching should include
instructions for parents about care
of the reconstructed area, doublediapering to
protect the stent, fluid intake,
medication administration, and
signs and symptoms of infection.
Tell parents when the child needs
to see the physician for dressing
removal..
Use double-diapering to protect
the stent (the small tube that
drains the urine).
Restrict the infant or toddler
from activities (e.g., playing on
riding toys) that put pressure on
the surgical site. Avoid holding
the infant or child straddled on the
hip. Limit the childs activity
for 2 weeks.
Encourage the infant or toddler
to drink fluids to ensure
adequate hydration. Provide fluids
in a pleasant environment or
using a special cup. Offer fruit
juice, fruit-flavored ice pops,
fruitflavored
juices, flavored ice cubes, and
gelatin.
Be sure to give the complete
course of prescribed antibiotics to
avoid infection.
Watch for signs of infection:
fever, swelling, redness, pain,
strongsmelling
urine, or change in flow of the
urinary stream.
The urine will be blood tinged
for several days. Call the physician
if urine is seen leaking from any
area other than the penis.
16

Surgical management

The management of hypospadias is surgical correction. The type of

procedures needed for reconstruction are dependent on the degree of
the hypospadias. Most of the mild forms can be corrected using a
single procedure in the outpatient setting, however, severe forms of
hypospadias may require two or more procedures for correction and
may need hospitalization. The goal of the reconstruction is to
straighten the penis (correct chordee), bring the opening meatus to the
tip of the penis, and make the penis as cosmetically close to the
normal as possible.
Although surgical correction can be performed at any age, most
pediatric urologists would do the surgery between 6 and 17 months of
age. Following surgery, a stent (tube) may be left in place in the
reconstructed penis to drain the urine and a dressing is left in place.
The length of time that the stent and dressing are used is variable, but
is most frequently a week. The dressings and the stent are removed in
the office.
Boys are treated with oral pain medication if they are operated
upon in the outpatient surgery center.
Complications following surgery include fistula hole in the
channel that is reconstructed diagnosed by noting urine dripping
from a second opening when the child is urinating; and meatal stenosis
scarring of the new opening diagnosed by a narrowing of the urine
stream.
Additionally the new channel that is created can scar and cause a
stricture or even complete breakdown of the repair is possible. All of
these complications require further surgical repair. With the advances
in the techniques of surgery, the complications have been reduced
considerably.
If hypospadias is noted at birth, it is STRONGLY recommended that
the child not have a circumcision. The foreskin that is removed at the
time of circumcision is used for the reconstruction of the hypospadias.

VII. Nursing Care Plan (page 18-19)

VIII. Drug Summary (page 20-21)

22

IX.

Discharge Planning

Medications
Exercise

Treatment
Health
Teaching
Out-Patient

Diet

Spiritual

Advise mother to follow all the prescribed medications.

Once the is at home, he does not have to stay in bed,
but he needs to be watched closely. He may walk and
play QUIETLY. Patient may not use straddle toys,
walkers, or bicycles until it is okayed by his doctor. His
doctor will also tell him when he can return to daycare
or school.
Apply anti-fungal medications like ketoconazole to the
area to prevent infections.
Always do proper hand washing. And proper hygiene.
Avoid strenuous activities that would lead to bleeding.
And have adequate rest.
Always have a regular check up at your nearest health
center or to your Doctor, at least once a week to
monitor the progress of the treatment. The client should
report immediately to the physician if there is unusual
ties occur. Follow up appointment in clinic.
Advice mother to give her son fruit juice, soups and
crackers to help prevent stomach upset. It is important
that his son drinks plenty of fluids. Give him foods high
in fiber, such as cereal or fruit to prevent constipation.
Always pray for the guidance of the Lord. Spiritual
health affects the wellness of an individual greatly.
Strengthen relationship with Lord by showing love and
respect to the people around you.

23

X.

Bibliography

BOOKS:
Brunner and Suddarths (Medical and Surgical Nursing)
Black Hawks (Medical and Surgical Nursing)
Elaine Marieb (Essential of Human Anatomy and Physiology)
Jossie Quiambao Udan (Concept and Clinical Application
Marilyn Doenges (Nurses Pocket Guide)
Lippincott Williams and Wilkins (Springhouse Nurse Drug Guide
2007)
Springhouse (Patient Teaching Reference Manual)
Sue Rodwell Williams (Basic Nutrition and Diet)

WEBSITE:
www.yahoo.com
www.nursingcrib.com
www.scribd.com
www.emedicine.medscape.com
www.wikipedia.org
www.healthsystem.edu
www.childrenspecialists.com