CHAPTER I

OPENING

1.1 Background
Hypospadias is an abnormality of anterior urethral and penile development in which
the urethral opening is ectopically located on the ventrum of the penis proximal to the tip
of the glans penis, which, in this condition, is splayed open. The urethral opening may be
located as far down as in the scrotum or perineum. The penis is more likely to have
associated ventral shortening and curvature, called chordee, with more proximal urethral
defects.
The earliest medical text describing hypospadias dates back to the second century AD
and was the work of Galen, the first to use the term. During the first millennium, the
primary treatment for hypospadias was amputation of the penis distal to the meatus. Since
that time, many have contributed to development of modern hypospadias repair. Over 300
different types of repairs have been described in the medical literature. Although most
reports have been in the last 60 years, most basic techniques were described over a
century ago.
Modern anesthetic techniques, fine instrumentation, sutures, dressing materials, and
antibiotics have improved clinical outcomes and have, in most cases, allowed surgical
treatment with a single-stage repair within the first year of life on an outpatient basis.

1.2 Problem Formulation

1.2.1 Definition of hypospadia
1.2.2 Etiology of hypospadia
1.2.3 Pathophisiology of hypospadia
1.2.4 Clinical manifestation of hypospadia
1.2.5 Test and diagnosis of hypospadia
1.2.6 Treatment of hypospadia
1.2.7 Complication of hypospadia
1.2.8 Pathway of hypospadia

1.3 Purposes
1.3.1 General Purpose
 After reading this paper the student can understand what is meant by nephrotic
syndrome and nursing care plan.

1.3.2 Special Purpose

After reading this paper, students can:
 Explain the definition of hypospadia
 Describe the etiology of hypospadia
 Describe the pathophysiology and WOC hypospadia
 Describe the clinical manifestations of hypospadia
 Explain the management of nephrotic hypospadia
 Explain the complications of nephrotic hypospadia
 Perform nursing care plan in patients with hypospadia
 CHAPTER II

RESEARCHES

2.1 Definiton

Hypospadia is a birth defect of the urethra in males and females that involves an
abnormally placed urinary meatus (the opening, or male external urethral orifice). 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, as is the case in pseudovaginal
perineoscrotal hypospadias. A distal hypospadias may be suspected in an uncircumcised boy
from an abnormally formed foreskin and downward tilt of the glans.

Hypospadias is a condition in which the opening of the urethra is on the underside of

the penis, instead of at the tip. The urethra is the tube through which urine drains from your
bladder and exits your body. Hypospadias refers to the urethral meatus being on the ventral
(under) surface of the penis instead of the end.

2.2 Classification

2.2.1 Anterior type or simple type : Clinically, this disorder are asymptomatic and do
not require an action. When the meatus rather narrow can be dilated or
meatotomi. Divided into :

a. glandulan (balantik) type is meatus located at penis groin.

b. Coronal type is meatus located at neck of penis

2.2.2 Middle type or penil type : Usually accompanied by comorbid disorders, namely

the absence of the ventral foreskin, so that the penis looks curved downward or
glands of the penis become compressed. In this type of disorder, surgical
intervention is required in stages, since the skin on the ventral foreskin not then
you should not be performed circumcision on the baby because the rest of the
skin that is can be useful for further surgery. Divided into :
 a. distal penil type is meatus located at distal penis.

b. penil type is located between perineal and scrotum.

c. scrotal type is located at scratum.

2.2.5 Posterior type : perineal type is meatus located at perineal. In this type, generally

the growth of the penis will be disrupted, sometimes accompanied by a bifid

scrotum, urethral meatus generally wide open and undescended testicles.

2.3 Etiology

According to the NIH (2008), hypospadias is a commonly occurring congenital

defect. Hypospadias can vary in everity and the opening can extend the length of the penis.
Beside of that, there are some factors that very take effect to hypospadias, such as :

2.2.1 Disorders and hormonal imbalances

The hormone is the androgen hormone that regulates organogenesis sex (male).
Or it could be because the hormone androgen receptor itself in the body that is less or
no. So although androgens themselves have formed enough but if the receptor no it
still will not give a proper effect. Or enzymes involved in androgen synthesis is
insufficient will have the same effect.

2.2.2 Genetic

It happens because failure of androegen synthesis. This usually occurs because

of a mutation in the gene encoding the androgen synthesis, so that the expression of
these genes does not occur.

2.2.2 Environment

  Usually the environmental factors that cause is pollutants and substances that
may contains teratogenic mutations that causing mutation.
2.4 Pathophisiology

Hypospadias is a congenital defect that is thought to occur embryologically during

urethral development, from 8-20 weeks' gestation. The external genital structures are
identical in males and females until 8 weeks' gestation; the genitals develop a masculine
phenotype in males primarily under the influence of testosterone. As the phallus grows, the
open urethral groove extends from its base to the level of the corona. The classic theory is
that the urethral folds coalesce in the midline from base to tip, forming a tubularized penile
urethra and median scrotal raphe. This accounts for the posterior and middle urethra. The
anterior or glanular urethra is thought to develop in a proximal direction, with an ectodermal
core forming at the tip of the glans penis, which canalizes to join with the more proximal
urethra at the level of the corona. The higher incidence of subcoronal hypospadias supports
the vulnerable final step in this theory of development.

In 2000, Baskin proposed a modification of this theory in which the urethral folds
fuse to form a seam of epithelium, which is then transformed into mesenchyme and
subsequently canalizes by apoptosis or programmed cell resorption. Similarly, this seam
theoretically also develops at the glanular level, and the endoderm differentiates to ectoderm
with subsequent canalization by apoptosis.

The prepuce normally forms as a ridge of skin from the corona that grows
circumferentially, fusing with the glans. Failure of fusion of the urethral folds in hypospadias
impedes this process, and a dorsal hooded prepuce results. On rare occasions, a glanular cleft
with intact prepuce may occur, which is termed the megameatus intact prepuce (MIP) variant.

Chordee, or ventral curvature of the penis, is often associated with hypospadias,

especially more severe forms. This is thought to result from a growth disparity between the
normal dorsal tissue of the corporal bodies and the attenuated ventral urethra and associated
tissues. Rarely, the abortive spongiosal tissue and fascia distal to the urethral meatus forms a
tethering fibrous band that contributes to the chordee.

2.5 Clinical Manifestation

 2.5.1 Males with this condition may also have a downward curvature of the penis,
called chordee, that becomes apparent with an erection.

2.5.2 Opening of the urethra at a location other than the tip of the penis
2.5.3 Downward curve of the penis (chordee)
2.5.4 Abnormal spraying during urination

2.6 Diagnosis

2.6.1 physical examination

Diagnosis is made by physical examination in newborns or infants. Because

other disorders may accompany hypospadias, it is recommended that a thorough
examination, including examination of chromosomes (Corwin, 2009).

2.6.2 Rontgen

2.6.3 USG urinary system

2.6.4 BNO – IVP because usually the hypospadias is also accompanied by congenital
kidney abnormality

2.6.5 Urine culture

2.7 Treatment

Circumcision should not be performed as the foreskin remnant is required for surgical
repair. There are 3 step of surgery for hypospadias, such as : meatotomy, chrodectomy and
urethroplasty. The surgical principles are:

a. To reposition the meatus on to the head of the penis (meatoplasty and glanduloplasty)
b. To straighten the chordee (othoplasty)
c. To correct the hooded foreskin (by circumcision)
d. To achieve all of this with an aesthetically acceptable result
 2.8 Complication

2.8.1 Infertility

2.8.2 High risk of hernia inguinalis

2.8.3 disorder of psycosocial

2.8.4 Preputium (kulup) tidak ada dibagian bawah penis, menumpuk di bagian
punggung penis.

2.8.5 Chrodee

2.8.6 Hernia Inguinali

2.8.7 Disorder to urinary adequately with standing position

2.8.7 Lower penis skin very thin

2.8.8 Undescended testis

.    
 CHAPTER III

NURSING CARE

3.1 Assessment
3.1.1 Identity
a. Age: children and adults
b. Gender: male

3.1.2 Main complaints :

a. Pre surgey : patients complaint that he can’t urinary adequatly with
standing position.
b. Post surgery : patient tell that he feel pain at flank.

3.1.3 Disease History Now :

a. Pre surgery : patient feel discomfort when urinary because can’t urinary
with standing position, the meatus urethra located between
perineal and scrotum. Patient tell that he affraid because his
meatus urethra is not at the right place. Patient looks anxiety.
b. Post surgery : after surgery patient feel pain at his flank. P : insist process,
Q : sharp pain, R : flank, S : >3, T : tidak menentu. Patient
looks winced in pain. Vital signs = BP : >120/80 mmHg,

pulse : >60-100x/m, RR : 16-20x/m.

3.1.4 Past history of disease :

Genetic

3.1.5 Family history of disease :

There are family members that have hypospadia disease.
3.1.6 Physical Examination :
 B1: RR = 16-20x/mnt
 B2: Blood pressure : >120/80 mmHg, Pulse :> 60-100x/min,
Temperature : 36,5-37,0
 B3: Flank pain
 B4: can’t urinary well with standing position
 B5: normal
 B6: Weakness

3.2 Nursing Diagnosis

Pre Surgery
DATA PROBLEM ETIOLOGY
DS : Distrurbance of Deformity
 patients complaint that he elimination urine
can’t urinary adequatly with Abnormal spraying during
urination
standing position.
DO :
 patient feel discomfort
when urinary because can’t
urinary with standing
position.
 the meatus urethra located
between
perineal and scrotum.
DS : Anxiety Undescended testicles
 Patient tell that he affraid
because his meatus urethra No produce Testosteron
is not at the right place.
DO : infertility
 Patient looks anxiety.
Post Surgery
DS : Acute Pain Meatotomy, chordectomy
and Urethroplasty
  patient tell that he feel
pain at flank. Surgery process
DO :
 after surgery patient
feel pain at his flank.
 P : insist process, Q :
sharp pain, R : flank,
S : >3, T : uncertain.
 Patient looks winced in
pain.
 Vital signs = BP :
>120/80 mmHg,
pulse : >60-100x/m,
RR : 16-20x/m.
DS : - High risk of infection Meatotomy, chordectomy
and Urethroplasty
DO : -

Chateter

Port de entry
Pre Surgery :

1) Distrurbance of elimination urine related to bnormal spraying during urination cause

by deformity marked with patients complaint that he can’t urinary adequatly with
standing position, patient feel discomfort when urinary because can’t urinary with
standing position and the meatus urethra located between perineal and scrotum.
2) Anxiety related to infertility caused by no produce testosteron marked with patient tell
that he affraid because his meatus urethra is not at the right place and patient looks
anxiety.

Post Surgery :

1) Acute pain related to surgery marked with patient tell that he feel pain at flank, after
surgery patient feel pain at his flank, P : insist process, Q : sharp pain, R : flank, S :
>3, T : uncertain, patient looks winced in pain, vital signs = BP : >120/80 mmHg,
pulse : >60-100x/min, RR : 16-20x/min.
2) High risk of infection related to infection driveway due to chateter.
3.3 Intervention

No. Nursing Diagnosis Goals and outcomes criterias Intervention Rational

PRE SURGERY
1. Distrurbance of elimination Distrurbance of elimination 1. Explain to the patient 1. Patient will understand
urine related to abnormal urine can handle during about the procedure. about his condition and
spraying during urination cause nursing care 3x24 hours with accept the procedure.
by deformity marked with outcomes criterias : 2. Collaborate with 2. To fix the position of
patients complaint that he can’t a. Patient cooperative physician to surgery meatus urethra, so patient
urinary adequatly with standing b. Patients can feel can urinary well with
position, patient feel discomfort comfortable when standing position
3. Observe patient’s
when urinary because can’t urinary 3. To check that patient can
condition after surgery
urinary with standing position c. The meatus urethra urinary adequatly
and the meatus urethra located located normaly
between perineal and scrotum.
2. Anxiety related to infertility Anxiety can handle during 1. Explain to the patient about 1. Patient will understand
caused by no produce nursing care 3x24 hours with the procedure about his condition and
testosteron marked with patient outcomes criterias : accept the procedure.
tell that he affraid because his a. Patient cooperative 2. Create a trusting 2. To make patient believe
meatus urethra is not at the right b. Patient can accept his relationship nurse for the treatment
place and patient looks anxiety. condition 3. Create a calm atmosphere 3. To make the patient more
c. Patient doesn’t feel relax
afraid and don’t feel 4. Listen attentively 4. To make patient more relax
 affraid and believe us
5. Identification of changes in 5. If the patient do not feel
the level of anxiety anxiety it means that the
treatment is success
POST SURGERY
1. Acute pain related to surgery Acute pain can handle 1. Explain to the patient 1. Patient will understand about
marked with patient tell that he during nursing care 3x24 about the procedur his condition and accept the
feel pain at flank, after surgery hours with outcomes procedure.
patient feel pain at his flank, P : criterias : 2. Give a comfort position to 2. Comfort position can
insist process, Q : sharp pain, a. Patient cooperative patient increasing clien’s comfortable
R : flank, S : >3, T : uncertain, b. The pain reducing 3. Instruct patient to do 3. Relaxation and distraction
patient looks winced in pain, c. Scale <3 relaxation and distraction technique will make patient
vital signs = BP : >120/80 d. Patient more technique more relax
mmHg, pulse : >60-100x/min, comfortable 4. Colaborate with physician 4. Analgesic can decrease the
RR : 16-20x/min. e. Vital signs normal to give analgesic medicine pain that patient feel.
5. Observe pain scale 5. Normal scale is an indicator
that acute pain can handle.
6. Observe vital signs 6. Vital signs is an indicator that
acute pain can handle.
7. With asking what he feel, we
7. Ask patient about what his
can know what patient feel
feel
after the intervention given.
 b

2. High risk of infection related to High risk can handle during 1. Explain to the patient 1. Patient will understand about
infection driveway due to nursing care 3x24 hours about the procedure his condition and accept the
chateter with outcomes criterias : procedure.
a. Patient cooperative 2. maintain sterility when do 2. Sterility will prevent the
b. No redness intervention inserting of bacteria
c. No burning feeling 3. maintain environmental 3. Maintain the sterility
d. No inflammation hygiene
4. colaborate with physician 4. Antibiotic can prevent the
to give antibiotic infection
medicines
5. observe area chateter 5. To know is there any signs of
infection or not
 CHAPTER IV

CLOSING

3.1 Conclusion
Hypospadia is a birth defect of the urethra in males and females that involves
an abnormally placed urinary meatus (the opening, or male external urethral orifice).
There are some factors that very take effect to hypospadias, such as disorders and
hormonal imbalances, genetic and environment.
Patient with hypospadias have clinical manifestation like males with this
condition may also have a downward curvature of the penis, called chordee, that
becomes apparent with an erection, opening of the urethra at a location other than the
tip of the penis, downward curve of the penis (chordee) and abnormal spraying during
urination. The nursing problem is divided for pre and post surgery.

3.2 Suggest and critic

If there are clinical symptoms such as can’t urinary with standing position and
the meatus urethra is not normal, immediately consult the nearest health officials to
determine whether you are suffering from hypospadias and can get help early.
 REFERENCES

Jones & Barlett. 2011. Pathophysiology. Lachel Story : United States of America.

Wilinson, Judith M & Nancy R. Ahern. 2012. Diagnosis Keperawatan Nanda NIC NOC.
EGC : Jakarta.
 Nursing urinary system
"The concept of the Medical and Nursing Care Clients with Hypospadia"

By :
 Feni J.C. Fina (9103011012)
 Aloisius Wandikmbo (9103012010)
 Marisya Oktaviani (9103012038)

Faculty of Nursing
Widya Mandala Catholic University
Surabaya

2014