Psychosocial functioning of children, adolescents, and adults following hypospadias surgery: a comparative study

Impact of the Age at Distal Hypospadias Surgery on Behavioral Problems, Somatic Symptoms and Irritability Levels in Children

BACKGROUND

To assess the effect of age at hypospadias surgery on emotional and behavioural problems, somatic symptoms, irritability, and penile perception.

METHODS

We retrospectively identified the patients who underwent single distal hypospadias surgery and age-matched healthy controls were included. There were two further subgroups according to the age at the time of hypospadias repair (<2 vs. >2 years). The Strengths and Difficulties Questionnaire (SDQ), Revised Children's Anxiety and Depression Scale (RCADS), Affective Reactivity Index (ARI), Level 2 Somatic Symptom Scale, and Penile Perception Score (PPS) scale were used. The groups were compared using multivariate variance analysis (MANOVA).

RESULTS

Both groups consisted of 70 patients (mean age 14.0 ± 0.2 years, for both), while there were 34 patients in the hypospadias groups who underwent surgery at <2 years of age. Depressive, panic, separation anxiety, social phobia, and somatic complaint symptom scores of the hypospadias group were lower than those of the control group. Obsessive-compulsive symptom levels were significantly higher in patients who underwent hypospadias surgery at >2 vs. <2 years of age. Additionally, PPSs rated by the surgeon were significantly higher in the former. A multivariate linear regression model indicated that panic disorder symptom scores predicted child PPS in the hypospadias group. Limitations include retrospective design.

CONCLUSIONS

Single hypospadias surgery seems not to have a negative impact on emotional and behavioural status. Children who underwent distal hypospadias surgery after 2 years of age had higher levels of obsessive-compulsive symptoms. Following emotional status may help the early diagnosis of future psychopathologies.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

Small Intestinal Submucosa for corporeal body grafting in patients with proximal hypospadias and severe chordee: Long term follow-up assessing erectile function and genital self-perception

BACKGROUND

Proximal hypospadias and severe ventral chordee are often challenging to repair. To preserve penile length in chordee repair, Small Intestinal Submucosa (SIS) corporal grafting is often performed with potential long-term complications including recurrent curvature and erectile dysfunction (ED). There is a paucity of data evaluating sexual function in mid, late and post-pubertal patients.

OBJECTIVE

We aimed to assess long-term outcomes of genital self-perception and erectile function in mid, late and post-pubertal patients who underwent single-layer (1-ply) SIS corporal body grafting for correction of severe chordee.

STUDY DESIGN

Patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting between 2001 and 2015 were retrospectively identified. Patients were evaluated for erectile and sexual function using the modified erection hardness score (mEHS) and the modified sexual health inventory for men (mSHIM). Perceived function and straightness were measured with Hypospadias Objective Scoring Evaluation (HOSE). Penile self-perception was assessed using the Pediatric Penile Perception Score (PPPS). Results were compared to an age-matched healthy control group. Categorical variables were analyzed using Fisher's exact test, and continuous variables using paired and unpaired t-test and ANOVA.

RESULTS

Nineteen patients with proximal hypospadias who underwent correction of severe chordee using SIS grafting and 18 controls participated in the study with a median age of 17 years for both groups. In the mEHS, 12 (63.2%) hypospadias-patients and 14 (87.5%) controls rated their erections as completely hard and very rigid. In the mSHIM, 1 (5.2%) hypospadias-patient was classified as having moderate ED. A total of 16 hypospadias-patients (84%) and 16 controls (88.9%) reported being very satisfied or satisfied with the straightness of their penis. No significant difference was observed in the mEHS, mSHIM and PPPS between groups (p < 0.05). The straightness of the erection was rated lower by participants, than by the pediatric urologist. In the HOSE, 12 (63.2%) hypospadias-patients and 16 (88.9%) controls obtained an acceptable score.

DISCUSSION

Our findings indicate favorable long-term outcomes in ED and genital self-perception; only 5% of our population reported having a mild-moderate to moderate presentation of ED, and there were no reports of severe ED. The overall PPPS satisfaction rates were statistically similar for the control and hypospadias groups. The small sample population limits the significance of our findings.

CONCLUSION

Corporal body grafting with 1-ply SIS suggests positive long-term outcomes in genital self-perception and erectile function, with mid, late and post-pubertal patients who underwent hypospadias repair having comparable results to age-matched healthy controls.

Hypospadias and Increased Risk for Psychiatric Symptoms in Both Childhood and Adolescence: A Literature Review

Hypospadias is one of the most common congenital malformations in boys. Due to abnormal appearance in the penis with abnormal urination and erection, patients with hypospadias were vulnerable to suffering from stress and psychiatric difficulties. The present study aims to summarize all the current evidence of the association between hypospadias and the risk of psychiatric disorders by a comprehensive review. Seventeen clinical studies were identified in the four electronic databases. A total of 953,872 participants were involved, while 15,729 of them were hypospadiac patients and the remaining 938,143 were normal controls. The standard age for surgery for hypospadias ranged from 20.4 months to 21.5 years. Eight out of seventeen (8/17, 47%) included studies explicitly showed that patients with hypospadias had a significantly higher risk of psychosocial disorders (all P < 0.05). Specific types of psychiatric disorders included depression, anxiety, shyness, timidness, isolation, fear of ridicule, attention-deficit hyperactivity, autism spectrum, behavioral/emotional disorders, temper tantrums, emotionality, affective, psychosexual problems, and suicidal tendencies. Based on this review, psychiatric illnesses are frequently detected in hypospadiac patients' childhood, thus proper psychiatric guidance and early interventions from physicians, nurses, and parents may help these children to grow into less affected men.

High satisfaction on genital self-perception and sexual function in healthy Norwegian male adolescents

BACKGROUND

Genital self-perception and self-reported outcome on sexual function represent important information in studies focusing on male adolescents born with a genital malformation. Normal data from an age-matched control group are essential for comparison and more knowledge is needed concerning age after puberty and before entering adulthood.

OBJECTIVE

To investigate the self-reported outcome on genital perception and sexual outcome of healthy male adolescents aged 16 and 17 years.

STUDY DESIGN

Sixty-one individuals were included in this cross-sectional study. The assessment tools included the adolescents' self-report on genital perception and sexual function measured by the Pediatric Penile Perception Score (PPPS) and their responses to a semi-structured interview. In addition, we added information on mental health and psychosocial functioning measured by the Strengths and Difficulties Questionnaire, and health-related quality of life (HRQoL) measured by the Pediatric Quality of Life Inventory. Body satisfaction and self-esteem were also measured by the Global Self-Worth and Physical Appearance subscales of the revised version of the Self-Perception Profile for Adolescents (SPPA).

RESULTS

Of the 73 individuals invited, a total of 61 participated. The adolescents reported high satisfaction on genital self-perception and sexual function with a score close to 10 on the overall PPPS score (maximum overall score is 12). Participants who were dissatisfied with their genitals reported penile length, alongside foreskin, as their main concern. More than 90% reported satisfaction on sexual function, concerning erection, masturbation, ejaculation, and orgasm. Results showed a higher score on body satisfaction, self-esteem, mental health and psychosocial functioning and a lower score on HRQoL compared to the normative Norwegian data. The small numbers of individuals that scored more negatively on genital self-perception and sexual function also scored more negatively in all items studied.

DISCUSSION

A key finding in our study was their high satisfaction on the overall PPPS score and reported sexual function. The results are comparable to other studies related to healthy male adolescents and the sample studied deviate little from a representative Norwegian sample. A comparison group of age-matched adolescents from the normative population is important to determine long-term outcomes on genital appearance and sexual function of patients born with a genital malformation and operated on in early childhood. Limitations of this study are the small sample-size and the lack of information on non-participants.

CONCLUSIONS

Our results show generally positive genital self-perception and sexual function in a healthy group of Norwegian male adolescents, aged 16 and 17.

The hypospadias-specific health-related quality of life conceptual framework: a scoping review of the literature

PURPOSE

Health-related quality of life (HRQoL) is an important yet understudied construct for individuals with hypospadias (HS). An important barrier towards understanding HRQoL and integrating it into research and clinical care for people with HS is the absence of an underlying conceptual framework to illustrate this construct. We propose a conceptual framework for HS-specific HRQoL based upon a scoping review of the HS literature.

METHODS/MATERIALS

We conducted a literature review of articles published between 1989 and 2019. Our search in Embase and Pubmed used the keyword "hypospadias" in combination with "quality of life" and "patient-reported outcomes." We used thematic analysis of the resulting publications to identify core HRQOL domains. From these results and review of HRQoL literature in other pediatric populations, we developed a conceptual framework representing HS-specific HRQoL.

RESULTS

We identified five domains of HRQOL previously studied in research with youth and adults with HS: penile appearance, voiding, social interaction, sexual health, and psychological or behavioral function. We propose a model of HS-specific HRQoL comprised of these domains and their areas of overlap, based upon the findings and conceptual mapping of our literature review.

CONCLUSION

This novel conceptual framework provides a foundation for understanding disease-specific HRQoL in individuals with HS and may serve as a guide for the conduct of future qualitative studies of the HS population. The overlapping biopsychosocial domains illustrate the possible effects of HS on day-to-day life. This framework may guide future surgical, clinical, and behavioral interventions that aim to improve medical care and quality of life outcomes for HS patients.

Evaluating quality of patient-reported outcome measures in patients with hypospadias

INTRODUCTION

There is growing recognition of the importance of patient-reported outcomes (PROs) in pediatric hypospadias. We have previously presented a conceptual framework for Hypospadias-Specific Health-Related Quality of Life (HRQoL), which posited 5 domains of HRQoL in this population. The framework components (domains) included penile appearance, voiding function, social function, psychological/behavioral function, and pubertal/sexual health. In this work, we investigated the established validity and relevance of PROs within each of these domains for patients with hypospadias.

MATERIALS AND METHODS

We evaluated existing measures with published psychometric data, including validation data, in the hypospadias population. We also assessed the available data on each measure according to the guidelines of the Scientific Advisory Committee of the Medical Outcomes Trust (Table) in order to establish measure quality. We also examined the power of existing validation studies according to suggested guidelines for psychometric validation and factor analysis.

DISCUSSION

Available validated measures in the hypospadias population have focused primarily on penile appearance and to a lesser degree on pubertal development/sexual health. There were no validated disease-specific measures with dedicated evaluations of other key HRQoL domains including voiding-related sequelae, social function, or psychological function. In addition, no single measure addressed all of the quality guidelines posed by the Scientific Advisory Committee.

CONCLUSIONS

Current generalized measures for PROs lack relevance to the experience of hypospadias patients, and disease-specific assessments are often focused on penile appearance. Improving measure quality is necessary to optimize the value of our assessments and better help our patients with hypospadias.

Recurrent Ventral Curvature with Long-Term Follow-up after Transverse Preputial Island Urethroplasty

OBJECTIVE

 This study was aimed to assess the long-term outcomes of recurrent ventral curvature (VC) repaired in early childhood after transverse preputial island flap urethroplasty.

MATERIALS AND METHODS

 A total of 378 patients underwent transverse preputial island flap urethroplasty between January 2000 and January 2005 at our hospital. Of these patients, 43 were invited for assessment of VC after puberty. The age at surgery, types of hypospadias, degrees of recurrent VC, and surgical procedures were analyzed.

RESULTS

 The study included 43 patients with a mean age of 15.9 years (range, 12.3-17.9). The average age at the time of primary surgery was 1.9 years (range, 1.2-3.6). Of 43 patients, recurrent VC was identified in 14 (32.5%). In total, 8 out of 16 patients (50.0%) were successfully treated by urethral plate transection with skin release during the primary surgery, and 6 out of 27 patients (28.6%) underwent additional dorsal plication (DP; p = 0.093). Severe recurrent VC was observed in four, moderate curvature was observed in four, and mild curvature was observed in six cases. Recurrent VC was present more often in patients with complications (34.6 vs. 24.1%, p = 0.331), especially in severe urethral strictures that required open surgical reconstruction (p = 0.039).

CONCLUSION

 Although the patients in our study represent only a small portion of the overall hypospadias population, it is notable that 32.5% of these patients showed recurrent VC, including 28.6% of patients with transection plus DP. We suggest long-term follow-up of hypospadias at least during adolescence or even into adulthood.

Mental health outcomes among individuals with 46,XY disorders of sex development: A systematic review

This review summarizes research on the mental health outcomes of genetic males with a disorder of sex development (46,XY DSD). Databases were systematically searched, yielding 19 studies included in this review. Results varied widely, with mental health outcomes ranging from very poor to similar to comparison groups. A small number of studies demonstrated that patients with hypospadias or complete androgen insensitivity syndrome reported better mental health than patients with other 46,XY (DSD) diagnoses. Future studies should include larger samples of patients within a similar developmental stage, display results separately by DSD diagnosis and gender identity, and consider the potential impact of medical/surgical events on their mental health.

Psychiatric symptoms in men with hypospadias - preliminary results of a cross-sectional cohort study

AIM

Population studies have shown an increased risk of neurodevelopmental disorders in males born with the congenital condition hypospadias, where the opening of the urethra is on the underside of the penis. We investigated overall psychiatric morbidity in cases and matched controls.

METHODS

This study compared 167 men born with hypospadias from 1959 to 1994 in Stockholm or Gothenburg in Sweden using hospital registers. They were compared with controls from the Swedish population registry, who were contacted by regular mail and students who were recruited by local advertisements. The total sample had a mean age of 33.5 years (range: 19-54). They completed self-rating scales for depressive, anxiety and obsessive-compulsive symptoms and symptoms of attention deficit hyperactivity disorder. In addition, 33 cases and 47 controls underwent psychiatric morbidity interviews that covered the 17 most common psychiatric diagnoses.

RESULTS

A fifth (21%) of both the cases and controls reported current or previous psychiatric symptoms. There were no significant differences in self-rated depression, anxiety or obsessive-compulsive disorder symptoms between the patients and controls or between the different phenotype groups. The distribution was not significantly affected by the severity of hypospadias.

CONCLUSION

Psychiatric morbidity was no higher in men with hypospadias than population-based controls.

Congenital genital abnormalities detected during routine circumcision at a South African institution: a retrospective record review

BACKGROUND

Due to the reduction in HIV transmission through male medical circumcisions (MMC), numerous clinics throughout South Africa offer a voluntary free service to boys from the age of ten years and above. An examination prior to the procedure may detect congenital abnormalities missed after birth.

OBJECTIVES

The aim of this study was to measure the incidence of these abnormalities, determine the demographic and clinical characteristics of this group and determine what referral systems, interventions, and follow-up is available to them.

METHODS

The study was a descriptive, observational, retrospective analysis of de-identified medical records at a routine MMC service at a Johannesburg clinic in 2015. The participants were male patients between the ages of 10 - 49.

RESULTS

Out of 1548 participants, 91.0% (n=1409) had a normal genital examination while 3.7% (n=57) had an abnormal examination and 5.1% (n=79) had no examination recorded. Thirty five congenital anomalies were detected and only 2 patients (diagnosed with hypospadias) were seen at the urology out-patient's department.

CONCLUSION

The incidence of congenital genital abnormalities of males presenting for routine circumcision is low. Despite the low incidence the effect on fertility, sexuality, ability to urinate and on psychological wellbeing is significant. Referral services to the urology department should be restructured to improve all outcomes.

Psychosocial outcomes in adult men born with hypospadias: A register-based study

In this nationwide matched cohort study, we have investigated whether being born with hypospadias affect subsequent psychosocial outcomes in adulthood. We analyzed prospectively collected data from national Swedish registers. Data on the diagnoses were collected from the National Patient Register and the Medical Birth Register. Data on psychosocial outcomes such as educational and income level, marital status and disability pension were collected from Statistics Sweden. The effects of covariates, such as age, county of birth, presence of other malformations and psychiatric illness, were taken into account. The associations between hypospadias and psychosocial outcomes were calculated using conditional logistic regression and expressed as odds ratios (OR) and 95% confidence intervals (CI). We included 4378 men diagnosed with hypospadias, born between 1969 and 1993 in Sweden. Patients with hypospadias were matched with unaffected men by year of birth and birth county. We did not detect any differences in educational or income level. The probability of entering marriage (OR 1.02, 95% CI 0.90-1.14) did not differ, regardless of phenotype. We did, however, detect a 40% increased probability of receiving a disability pension, (OR 1.39, 95% CI 1.20-1.61). In conclusion, men born with hypospadias in Sweden do not differ from unaffected men with respect to the majority of psychosocial outcomes studied. They are, however, at increased risk of receiving a disability pension, which motivates further investigations.

Assessing quality of life of patients with hypospadias: A systematic review of validated patient-reported outcome instruments

BACKGROUND

Patient-reported outcomes have the potential to provide invaluable information for evaluation of hypospadias patients, aid in decision-making, performance assessment, and improvement in quality of care. To appropriately measure patient-relevant outcomes, well-developed and validated patient-reported outcome (PRO) instruments are essential.

OBJECTIVE

To identify and evaluate existing PRO instruments designed to measure quality of life and/or satisfaction of individuals with hypospadias that have been developed and validated in a hypospadias population.

METHODS

A systematic search of MEDLINE, EMBASE, PsycINFO, CINAHL and Health and Psychosocial Instruments was conducted in April 2016. Two reviewers independently assessed studies and identified PRO instruments for inclusion. Data were extracted on study characteristics, instrument development and validation, and content domains.

RESULTS

A total of 32 studies were included that used or described five PRO instruments: Hypospadias Objective Scoring Evaluation (HOSE), Pediatric Penile Perception Score (PPPS), Penile Perception Score (PPS), Genital Perception Scale (GPS) for adults, and GPS for children/adolescents. Instrument development and validation was limited. The majority of identified instruments focused on postoperative cosmetic satisfaction, with only one instrument considering urinary function, and no instruments evaluating sexual function and psychosocial sequelae.

CONCLUSIONS

While many hypospadias studies have acknowledged the necessity of a patient-reported element, few have used validated PRO instruments developed in a hypospadias population. Existing instruments to measure patient-reported outcomes in hypospadias require improvement in both the breadth of content and in their development and validation methodology.

Clitoral hoodplasty in females with disorders of sex development

INTRODUCTION

The surgical management of girls with masculinized genitalia is gradually changing towards a more conservative approach. Reports on loss of clitoral sensitivity and related impairment of sexual function in women after feminizing genital surgery in childhood have been pivotal in this evolution. An exposed clitoral glans is occasionally seen at follow-up, and while patients may complain of aesthetics, no clitoral discomfort secondary to glans exposure has been reported. A technique has been developed to reconstruct the clitoral hood and the present study reports the preliminary results.

OBJECTIVES

To report the novel technique and preliminary results of clitoral hood reconstruction to cover an exposed glans after previous clitoroplasty in patients with congenital adrenal hyperplasia (CAH).

PATIENTS AND METHODS

Six female patients (mean age 13, range 4-21 years) with CAH sought medical help for clitoral concerns after previous reduction clitoroplasty. In two of the six patients, the main complaint was clitoral hypersensitivity or even pain. The clitoral glans was completely exposed in all patients, who were subsequently treated with a bi-laminar V-Y clitoral hoodplasty to create a mobile and natural-looking clitoral hood composed of an inner and outer preputial skin layer.

RESULTS

Postoperative covering of the glans was complete in five patients, and partial in one. The two patients with pre-operative pain became asymptomatic; all six patients were pleased with the cosmetic postoperative results.

CONCLUSION

Clitoral hoodplasty provides simple, yet effective, relief for women with cosmetic concerns or clitoral discomfort after previous feminizing surgery.

Psychosocial outcome in adult men born with hypospadias

INTRODUCTION

Hypospadias, which is a surgically treated congenital malformation of the male urethra, may have a negative impact on quality of life. This aspect has previously been subject to limited research. This study examined the long-term psychosocial outcome of a large cohort of adult males born with hypospadias.

OBJECTIVE

The purpose of this case-control study was to assess a possible negative influence on the psychosocial outcome in adult males with hypospadias.

STUDY DESIGN

Males with hypospadias treated in Sweden and aged ≥18 years old participated in this follow-up study. Age-matched men and university students were recruited as controls. The participants answered a questionnaire designed to reflect the subjective quality of life, social factors, need of support and follow-up, and the perceived impact of the disease upon upbringing. It also looked at the validated Psychological General Well-Being (PGWB) questionnaire and Relationship Questionnaire (RQ).

RESULTS AND DISCUSSION

A total of 167 patients (median age 34 years, 63% distal, 24% mid, and 13% proximal hypospadias) and 169 controls (median age 33 years) participated in the study. Patients had their first operation at 4 years of age (median) and the median follow-up time was 29 years following the first surgery. Men with hypospadias had a comparable total quality of life level with a mean total PGWB score of 82 (normal range 78-83) compared with 85.6 in controls. Scores on wellbeing and vitality were lower, even if the differences were small. Hypospadias did not affect marital status, presence of children in the family, frequency of employment or experience of bullying. These men more often lived at home with their parents (P=0.001) and had a lower level of education (P=0.004), even if the educational level in both patients and controls was high compared with the general Swedish population. Patients with proximal hypospadias were shorter compared with controls (P=0.003), which was consistent with the prenatal growth restriction associated with hypospadias. The group with proximal hypospadias expressed a greater need for medical (45.5%) follow-up compared with mid (28.2%) and distal (18.1%) cases (P=0.001). Patients with proximal hypospadias tended to avoid close relationships because of fear of being hurt.

CONCLUSIONS

The findings suggested that patients treated for hypospadias have a good HRQoL, can be expected to have a normal psychosocial life, and marry and have children. Repeated follow-up and psychological support during childhood/adolescence is however of great importance for patients with more proximal hypospadias.

The SIGHT questionnaire: A novel assessment tool for Satisfaction In Genital Hypospadias Treatment

PURPOSE

Psychosexual development is currently underrepresented in hypospadias outcome research. The aim of this study was to develop and validate a questionnaire addressing psychosexual long-term satisfaction, specifically of adolescent patients, after hypospadias repair.

MATERIALS AND METHODS

In a multistep participative design we identified key interests of adolescent patients with hypospadias. Next, a questionnaire addressing specifically the psychosexual satisfaction of adolescents after hypospadias repair was established. A population of 109 former patients with hypospadias was then assessed using this questionnaire. Furthermore, functional and cosmetic aspects, behavioural anomalies, and sexual activity were investigated. Age-matched patients undergoing circumcision served as control patients. Possible influence factors on patient satisfaction were investigated. Clinical trial registry site: German Registry of Clinical Trials DRKS, Freiburg, Germany (Reference: DRKS00003432).

RESULTS

Key interests of adolescent patients were "normal appearance of the penis", "normal function of the penis regarding voiding and sexual activity", "no limitations regarding cosmetic appearance to others", "no limitations to sexual activity", and an "unimpaired masculine identity". The "Satisfaction In Genital Hypospadias Treatment" (SIGHT) questionnaire was developed using these items and using previously published evaluation systems. Nine questions address psychosexual aspects and two additional questions address current sexual activity. Internal consistency was high and retest reliability acceptable. The patient population showed a normal strength and difficulties score (SDQ). Overall satisfaction was high and similar to that of the control group. In a Spearman correlation a high SDQ value, erectile problems, and complications correlated negatively with satisfaction.

CONCLUSION

To date, few studies have examined patients' satisfaction and psychosexuality. To our knowledge, the SIGHT questionnaire is the first to be developed participatively and in a stepwise fashion in collaboration with a paediatric psychologist and an open approach to determine items specifically important for adolescents. The SIGHT questionnaire can thus offer a relevant assessment of patients' psychosexual satisfaction. It is most suitable to supplement current strategies that so far mostly neglect the impact on psychosexual wellbeing.

Can we assess risk of psychiatric sequelae from perinatal injuries?

Medical malpractice litigation involving seven to nine figure settlements has been on the rise over the past decade. Given the life-altering scope of these incidents, forensic child psychiatrists may be asked to opine on the effects of a permanent perinatal injury on normal human development. Whether forensic child psychiatrists can assess risk of future psychiatric effects from such incidents is an important question. This paper is spurred by two separate cases, each involving a male infant having a portion of their genitals accidentally amputated by an obstetrician-gynecologist (OB/GYN) during a routine circumcision. In each case, the genitals were repaired, but permanent defects remained. The question arises how such injuries would affect these children as they matured. An analysis of the literature supported that there are risks of psychiatric effects of such birth-related injuries. Such predictions are made with reference to what is already known about human development, and by an exploration of the literature on the psychiatric effects of comparable injuries to children.

Hypospadias and increased risk for neurodevelopmental disorders

BACKGROUND

Hypospadias (aberrant opening of the urethra on the underside of the penis) occurs in 1 per 300 newborn boys. It has been previously unknown whether this common malformation is associated with increased psychiatric morbidity later in life. Studies of individuals with hypospadias also provide an opportunity to examine whether difference in androgen signaling is related to neurodevelopmental disorders. To elucidate the mechanisms behind a possible association, we also studied psychiatric outcomes among brothers of the hypospadias patients.

METHODS

Registry study within a national cohort of all 9,262 males with hypospadias and their 4,936 healthy brothers born in Sweden between 1973 and 2009. Patients with hypospadias and their brothers were matched with controls by year of birth and county. The following outcomes were evaluated (1) any psychiatric (2) psychotic, (3) mood, (4) anxiety, (5) eating, and (6) personality disorders, (7) substance misuse, (8) attention-deficit hyperactivity disorder (ADHD), (9) autism spectrum disorders (ASD), (10) intellectual disability, and (11) other behavioral/emotional disorders with onset in childhood.

RESULTS

Patients with hypospadias were more likely to be diagnosed with intellectual disability (OR 3.2; 95% CI 2.8-3.8), ASD (1.4; 1.2-1.7), ADHD (1.5; 1.3-1.9), and behavioral/emotional disorders (1.4; 1.2-1.6) compared with the controls. Brothers of patients with hypospadias had an increased risk of ASD (1.6; 1.3-2.1) and other behavioral/emotional disorders with onset in childhood (1.2; 0.9-1.5) in comparison to siblings of healthy individuals. A slightly higher, although not statistically significant, risk was found for intellectual disability (1.3; 1.0-1.9). No relation between other psychiatric diagnosis and hypospadias was found.

CONCLUSIONS

This is the first study to identify an increased risk for neurodevelopmental disorders in patients with hypospadias, as well as an increased risk for ASD in their brothers, suggesting a common familial (genetic and/or environmental) liability.

Behavioural outcome in children with congenital adrenal hyperplasia: experience of a single centre

The aim of this study was to determine the behavioral outcome in children with CAH and to identify the risk factors that may influence it. Participants (aged 6-18 years) included 29 girls and 20 boys with CAH and unaffected siblings (25 girls and 17 boys). Psychological adjustment was assessed with parent reports on the Child Behavior Checklist (CBCL). Information about disease characteristics was obtained from medical records. Our study reveals that there was higher incidence of parent-reported problem of anxious/depressed and withdrawn/depressed behaviours, somatic complaints, social, thought, and attention problems, and rule-breaking, aggressive, internalizing, and externalizing behaviour among children with CAH compared to controls. The prevalence of internalizing behaviour problems was higher in CAH boys compared with that of controls. Psychosocial adjustment of girls with CAH was found to be similar to unaffected female controls and was within the normal population range. Family income may be associated with behavioral outcome. Glucocorticoid dose may reflect disease severity which may be associated with behavioral outcome. We conclude that internalizing behavioral problem was prevalent among boys with CAH reflecting maladaptive adjustment in coping with chronic illness. This highlighted the importance of psychological and social support for the patients and their families.

Health-related quality of life in men with corrected hypospadias: an explorative study

OBJECTIVE

The aim of the study was to evaluate health-related quality of life (HRQoL) of men with a corrected hypospadias in comparison to circumcised controls. Furthermore, determinants of HRQoL were examined.

PATIENTS AND METHODS

In a cross-sectional study, HRQoL of 45 men with corrected hypospadias (mean age: 26.2 years +/- 5.1) was compared with a control group of 46 circumcised men (mean age: 25.5 years +/- 4.9). Participants answered three questionnaires: The Medical Outcomes Study Short Form-36 item questionnaire (SF-36), the International Index of Erectile Function (IIEF), and the Penile Perception Score (PPS).

RESULTS

Physical and mental dimensions of HRQoL were not impaired among men with corrected hypospadias if compared to circumcised men. Neither socio-demographic and medical variables nor erectile function (EF) predicted HRQoL. However, a negative genital self-perception (PPS) and a lower orgasmic function (OF) were risk factors for an impaired mental HRQoL.

CONCLUSIONS

Our data suggest that the HRQoL of adult hypospadias patients is comparable to that of circumcised men. However, patients should be supported in developing a positive genital self-perception, because poor genital self-perception correlated with an impaired mental HRQoL. Since studies with non-operated men suggest that some adapt well to their penile condition, further studies should also include non-operated hypospadias.

Different outcomes of hypospadias surgery between north america, europe and china: is patient age a factor?

Background and Objects

The patient’s age at the first hypospadias repair may be an important factor for determining postoperative outcomes. Age at the first procedure differs between Western countries and medical centers in China. This review examines the differences between the incidence of surgical complications and surgical age in boys receiving hypospadias repairs in North America, Europe and China.

Materials and Methods

Literature reports were reviewed in PubMed and WanFang databases using the key terms and phrases; ‘hypospadias outcomes’, ‘complications of hypospadias repair’ and ‘timing of hypospadias repair’. All peer-reviewed articles published over the past decade (2001-2011) were considered if; a full text was available, the article included age at the first hypospadias procedure and surgical complications.

Results

In total, 16 131 patients were reported in 113 papers from North America, Europe and China according to our inclusion criteria. There was a significant difference in age at the first hypospadias surgery (P < 0.0005) and in the incidence of complications (P <0.001) between the different global regions investigated, with the earliest surgeries occurring in North American patients. Urethral fistulas were the most common complication reported in all of the regions included in this study.

Conclusions

Fellowship training in pediatric urology could improve surgical outcomes, particularly in young children. Younger children experience fewer complications following hypospadias surgeries, independent of training and access to resources.

Factors associated with delayed pediatric hypospadias surgery in Taiwan: a population-based, nationwide analysis

BACKGROUND/PURPOSE

Current guidelines recommend that hypospadias repair should be performed before age 18 months. This study aims to investigate the trends of surgical timing and to determine what factors are associated with age at surgery.

METHODS

The present study utilized a subset of the National Health Insurance Research Database, known as Longitudinal Health Insurance Database 2005, which contains the data of all paid medical benefit claims over the period from 1997 to 2007 for a subset of one million beneficiaries randomly drawn from the population of 22.72 million individuals in NHI program during any part of calendar year 2005. We analyzed claims data for all subjects with the diagnoses of hypospadias.

RESULTS

Among 52,705 live male newborns, 218 were diagnosed with hypospadias and thus were included as subjects in our study. Among them, 89 received repair surgery. Approximately 60.6% of the study subjects received repair after the age of 18 months. Multivariate analysis showed that several factors were significantly associated with age at hypospadias surgery: specialty of clinics where first diagnosis was made; specialty of physician making the first diagnosis, age of physician making the first diagnosis; specialty of surgeon performing the surgery; number of years since surgeon's board certification; urbanization level of subject's residence; modality of surgery; concomitant cryptorchidism; concomitant prematurity and low birth weight; age at diagnosis; and number of well-baby clinic visits.

CONCLUSION

This study addresses an important issue of delayed hypospadias surgery in Taiwan, which provides a potential opportunity for improvement in quality of care.

Economic evaluation of anti-epileptic drug therapies with specific focus on teratogenic outcomes

BACKGROUND

Anti-epileptic drugs are known to be teratogenic, yet many women do need to continue the anti-epileptic drug use during pregnancy.

OBJECTIVES

To perform an economic evaluation of the anti-epileptic drug choice in young women who potentially wish to become pregnant. In particular, to estimate the impact of teratogenicity on the costs per quality adjusted life year (QALY).

METHODS

A decision-tree model is used to calculate the costs per QALY, taking into account the malformation risk in offspring due to the exposure to carbamazepine, lamotrigine or valproic acid, based on the European birth cohort of 2007. Probabilistic sensitivity analyses were performed using Monte Carlo simulation.

RESULTS

Valproic acid is dominated by carbamazepine after rank ordering on costs. The incremental cost-effectiveness of lamotrigine vs carbamazepine was estimated at €175,534 per QALY. Although valproic acid was dominated by carbamazepine in terms of costs and related effects, it is clinically relevant to compare lamotrigine with valproic acid. In particular, treatment options are dependent on several individual and clinical characteristics and these agents are therefore not always considered as interchangeable for all specified populations. The incremental cost-effectiveness for lamotrigine vs valproic acid was estimated at €13,370 per QALY. With assuming a willingness to pay threshold of €50,000 per QALY, results from the probabilistic analysis resulted in an acceptance level for lamotrigine vs carbamazepine and lamotrigine vs valproic acid of 4% and 99%, respectively.

CONCLUSION

Based on epidemiological data it is advised to whenever possible avoid valproic acid during pregnancy. Both carbamazepine and lamotrigine are estimated to be cost-effective treatment options vs valproic acid if focused on teratogenicity.

The psychosexual aspects of hypospadias repair: A review

OBJECTIVE

To review the psychosexual effects on men after hypospadias repair.

METHODS

We reviewed all English-language publications in the MEDLINE database from the US National Library of Medicine with the search terms 'hypospadias adult', 'psychosexual hypospadias', 'psychosocial hypospadias', and 'social hypospadias'. Each term returned 1036, 35, 19 and 68 results, respectively, which were reviewed.

RESULTS

While improvements in surgical techniques have improved function, the abnormality and repair still causes a disruption in perceived quality of life for many men. After repair, many men suffer from a negative view of their genitals and some degree of sexual inhibition. However, they still maintain a satisfactory sex life.

CONCLUSIONS

Psychosexual effects of hypospadias repair they endure in adulthood, although affected men maintain satisfaction with their sexual life.

Children with disorders of sex development: A qualitative study of early parental experience

BACKGROUND

Clinical research on psychological aspects of disorders of sex development (DSD) has focused on psychosexual differentiation with relatively little attention directed toward parents' experiences of early clinical management and their influence on patient and family psychosocial adaptation.

OBJECTIVES

To characterize parental experiences in the early clinical care of children born with DSD.

STUDY DESIGN

Content analysis of interviews with parents (n = 41) of 28 children, newborn to 6 years, with DSD.

RESULTS

Four major domains emerged as salient to parents: (1) the gender assignment process, (2) decisions regarding genital surgery, (3) disclosing information about their child's DSD, and (4) interacting with healthcare providers. Findings suggested discordance between scientific and parental understandings of the determinants of "sex" and "gender." Parents' expectations regarding the benefits of genital surgery appear largely met; however, parents still had concerns about their child's future physical, social and sexual development. Two areas experienced by many parents as particularly stressful were: (1) uncertainties regarding diagnosis and optimal management, and (2) conflicts between maintaining privacy versus disclosing the condition to access social support.

CONCLUSIONS

Parents' experiences and gaps in understanding can be used to inform the clinical care of patients with DSD and their families. Improving communication between parents and providers (and between parents and their support providers) throughout the early clinical management process may be important in decreasing stress and improving outcomes for families of children with DSD.

Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood

OBJECTIVE

Long-term results of hypospadias repair are scarce. Previous reviews mostly described mid-term results making extrapolation to long-term results difficult. This systematic review on long-term results in postpubertal men after hypospadias repair in childhood, aims to inform urologists and parents of a newborn boy with hypospadias about future expectations.

METHODS AND MATERIALS

The Pubmed/Medline and Embase databases were searched until February 2010. Inclusion criteria stated that patients with hypospadias were operated before the age of 6 years and were older than 14 years at follow up. Results were pooled and analyzed using SPSS 16.0. Data on proximal hypospadias patients and controls are described separately.

RESULTS

Twenty eligible studies investigating micturition, cosmesis and psychosexual functioning were found. Hypospadias patients report more urinary symptoms and have a lower Qmax than controls. Patients are less satisfied with penile appearance compared to controls. Objectively assessed cosmetic results are good. Sexually, patients are as active as controls, but are less satisfied. Patients less often have an intimate relationships compared to controls.

CONCLUSION

Study outcomes were heterogeneous due to operation techniques and a lack of validated questionnaires and control groups. Long-term results of hypospadias patients should be measured in a prospective design using validated measurement tools.

Online hypospadias support group data analysis

BACKGROUND

Although hypospadias is the most common malformation of the penis, this condition is virtually unknown to the general population. This lack of information may lead to psychological distress to both parents and patients. In this study the content of an Internet-based hypospadias support group is analyzed.

MATERIALS AND METHODS

All comments and postings made by members of an online support group between 2001 and 2008 were analyzed. No personalized data were used for evaluation.

RESULTS

At the end of 2008, the group consisted of 535 members. In the study period, 3050 postings were published. Major issues discussed in the group were (a) medical questions, exchange of medical knowledge, experience, and history; (b) psychological, ethical, and philosophical aspects; (c) practical questions and recommendations; (d) recommendations for surgeons; and (e) hypospadias in adults.

CONCLUSIONS

Online hypospadias support groups play an important role in how parents and patients cope with the condition. Surgeons dealing with hypospadias should be aware of the importance of Internet-based information in the field of hypospadias. They may benefit from the valuable feedback information from patients and parents to improve their practice and outcome.

Psychosexual adjustment and age factors in 130 men undergone hypospadias surgery in a Chinese hospital

The study investigated the psychosexual status and sexual function in adults who had hypospadias surgery at different ages. A detailed questionnaire was mailed to 130 patients who underwent hypospadias surgery between January 1988 and December 2007, and 50 healthy males who served as the control group. The patients were divided into three groups based on their age at which surgery was completed: group A (n=32; <10 years); group B (n=45; 10-18 years); and group C (n=53; >18 years). The Zung Self-Rating Anxiety Scale and The Zung Self-Rating Depression Scale were used to assess psychosexual status; a designed questionnaire and the International Index of Erectile Function-5 were used to assess sexual function. The incidence of anxiety and depression was significantly higher in patients than that in controls (P < 0.001), and was correlated with the age at which surgery was completed. The length and circumference of penises in patients were shorter than those of control groups with statistically significant differences (P < 0.01). There were no significant differences between patients and controls regarding libido strength, overall sexual satisfaction and erectile function (P > 0.05). In conclusion, difference existed in certain aspects of psychosexual and penile development between patients and controls. Hypospadias surgery should be performed early.

Social-adaptive and psychological functioning of patients affected by Fabry disease

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by the deficiency of alpha-galactosidase A. In addition to the debilitating physical symptoms of FD, there are also under-recognized and poorly characterized psychiatric features. As a first step toward characterizing psychiatric features of FD, we administered the Achenbach adult self report questionnaire to 30 FD patients and the Achenbach adult behavior checklist questionnaire to 28 partners/parents/friends of FD patients. Data from at least one of the questionnaires were available on 33 subjects. Analysis focused on social-adaptive functioning in various aspects of daily life and on criteria related to the Diagnostic and statistical manual of mental disorders IV (DSM-IV). Adaptive functioning scale values, which primarily measure social and relationship functioning and occupational success, showed that eight FD patients (six female and two male) had mean adaptive functioning deficits as compared to population norms. Greater rates of depression (P < 0.01), anxiety (P = 0.05), depression and anxiety (P = 0.03), antisocial personality (P < 0.001), attention-deficit/hyperactivity (AD/H; P < 0.01), hyperactivity-impulsivity (P < 0.01), and aggressive behavior (P = 0.03) were associated with poorer adaptive functioning. Decreased social-adaptive functioning in this study was not statistically significantly associated to disease severity, pain, or level of vitality. This study shows for the first time that FD patients, particularly women, are affected by decreased social-adaptive functioning. Comprehensive treatment plans for FD should consider assessments and interventions to evaluate and improve social, occupational, and psychological functioning. Attention to the behavioral aspects of FD could lead to improved treatment outcome and improved quality of life. Individuals affected by Fabry disease exhibited social-adaptive functioning deficits that were significantly correlated with anxiety, depression, antisocial behavior, and AD/H problems in a sampling of our male and female patients aged between 18 years and 59 years.

Psychological adjustment and sexual development of adolescents with disorders of sex development

PURPOSE

Disorders of sex development (DSD) are a heterogeneous group of congenital conditions characterized by an atypical development of chromosomal, gonadal, or anatomical sex. Particularly at the time of expected puberty, adolescents with DSD may become aware of being different from peers. This study explores the effect of DSD on psychosocial well-being and sexual development.

METHODS

We interviewed 60 adolescents aged 13-16 years with a DSD. To measure health-related quality of life, mental health, and body image, we used standardized instruments and additional questions related to sexuality and coping with DSD. Reference and control data were available from the German Health Survey for Children and Adolescents (Kiggs) and from a secondary school survey.

RESULTS

The general psychological well-being of adolescents with DSD was not impaired. However, outcomes related to adolescent developmental tasks like sexual activities demonstrated impaired participation, especially girls with DSD reported fewer sexual activities than female controls. Adolescents who needed hormonal treatment to induce puberty reported impaired well-being in nearly all outcomes in contrast to those who entered puberty spontaneously.

CONCLUSIONS

Interdisciplinary health care teams should focus on the pressure of conformity and openly discuss it with the adolescent in context of treatment decisions. Furthermore, special counseling concerning sexuality and coping with the condition in daily life is needed.

Body image and sexuality in adolescents after hypospadias surgery

OBJECTIVE

Patients operated on for hypospadias often display a range of emotional and functional postoperative problems at an early age. This study explores the social, psychosocial and sexual development of adolescent boys operated on for hypospadias at an early age.

PATIENTS AND METHOD

Ten boys between the ages of 11 and 18 years and an age-matched reference group of 10 boys completed three mailed questionnaires: the Child Behavior Checklist/4-18, the Youth Self Report, and the Self-Perception Profile for Adolescents. Data on body image and genital perception, and on social, psychosocial and sexual development were gathered by interview and standardized questionnaire.

RESULTS

Internalizing or externalizing problems were not reported to be increased. Boys operated on for hypospadias had a significantly lower score on the Self-Perception Profile for Adolescents, Social Acceptance subscale. Fewer boys in the clinical group considered their penis to be normal or judged their penis as similar to that of friends. No difficulties were found regarding psychosocial or sexual development; there was however a tendency towards a more negative genital appraisal.

CONCLUSION

Boys operated on for hypospadias appear to experience normal social, psychosocial and sexual development.

Long-term sexual activity status and influencing factors in men after surgery for hypospadias

The aim of this study was to compare the long-term postoperative status of hypospadiac patients by analysing their sexual psychology, sexual behaviour, sexual function and influencing factors. A total of 130 hypospadiac patients hospitalized between January 1988 and December 2007 were followed up with questionnaires using Zung's Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS), a self-designed sexual function questionnaire and a 5-item version of the International Index of Erectile Function (IIEF-5). The surveys served to evaluate the effects of hypospadias type, number of operations and surgical procedures on sexual psychology, sexual behaviour and sexual function. The control group consisted of 50 healthy adults. The postoperative SDS / SAS scores and occurrences of depression/anxiety in hypospadiac patients were significantly higher than those of normal controls (P < 0.001). Patients with proximal hypospadias and multiple procedures differed from those with distal hypospadias and a single procedure in all parameters of sexual psychology (P < 0.05). The average penile lengths and circumferences of hypospadiac patients under either erect or flaccid conditions were significantly shorter than those of normal controls (P < 0.001). A similar difference existed between patients with distal and proximal hypospadias (P < 0.01). There was no significant difference in any parameter of sexual function between patients with different numbers of operations and surgical procedures. Hypospadiac patients were clearly impaired in sexual psychology and penile development. The severity of hypospadias and number of operations were key factors that influenced the sexual psychology of patients. This finding indicated the importance of long-term follow-up and psychological counselling for hypospadiac patients postoperatively.

Health-related quality of life and psychological adjustment of children and adolescents with hypospadias

OBJECTIVE

To assess health-related quality of life (HRQoL) and psychological adjustment of children and adolescents after hypospadias repair and to identify sociodemographic, medical, and psychosocial predictors of outcome.

STUDY DESIGN

77 boys (7-17 years old) who underwent surgery for hypospadias were investigated in a cross-sectional study. Child- and mother-rated HRQoL was evaluated by the TNO-AZL Child Quality of Life Questionnaire, psychological adjustment by the Child Behavior Checklist. Scores were compared with an age-matched control group consisting of 77 boys after hernia repair.

RESULTS

Compared with the control subjects, self-reported HRQoL of patients with hypospadias was lower in most dimensions. In contrast, mother-reported HRQoL and psychological adjustment did not differ in the 2 groups. Higher age and "being less ashamed of penile appearance" predicted better self-reported HRQoL, whereas positive penile self-perception, the patient's experience of not having been teased about his penis, and more severe hypospadias contributed to better mother-reported HRQoL. Psychological adjustment was predicted by higher age, Swiss nationality, more severe hypospadias, and the patient's experience of not having been teased about his penis.

CONCLUSIONS

In contrast to psychological adjustment, self-reported HRQoL of boys with hypospadias can be diminished. Psychosocial factors are more important predictors than medical variables.

[The psychosocial/-sexual development of boys with hypospadias]

Boys with hypospadias can suffer from specific psychological stress as a result of genital surgery and a cosmetically and/or functionally impaired penis. During recent decades intensive efforts have been made to improve the surgical techniques; yet the psychosocial and psychosexual development of children and adolescents after hypospadias surgery has only rarely been investigated. While the results of the few studies are altogether very contradictory, they also indicate that hypospadias patients suffer from specific problems like a negative perception of genital appearance. Therefore, they should be offered long-term follow-ups and psychosocial support until they reach young adulthood. For future research, it is necessary to systematically investigate the boys' quality of life and development in methodologically sound studies.

Psychosocial aspects of andrologic disease

This article reviews the research relating to the psychosocial aspects of andrologic disease, focusing on infertility, hypospadias, and erectile dysfunction because these diseases draw out the key areas of psychosocial interest. This is the case with the development of men who have andrologic disease and the problems they face developing relationships. Psychosocial issues are often about the perceptions that men and women have regarding androgenic disorders rather than the disorder itself. Psychological problems include anxiety, depression, and social phobias. In more serious cases, psychological problems can affect masculinity, selfhood, and identity. Clinical psychologists and other psychotherapists can offer some assistance regarding these perceptions, but where there are problems relating to personality and coping styles, these may be more difficult to overcome. More research is required to understand the specific psychosocial consequences of androgenic disorders.

Long-term outcome following hypospadias repair

Hypospadias is a common problem affecting approximately one boy in 300; it is usually corrected in the first few years of life. While early outcome data is widely available, little has been reported on the long-term problems that these men suffer. Data suggest that the majority of men have no lasting effects, but up to 40% with severe hypospadias can have some degree of voiding problems. In addition, sexual problems affecting erection, ejaculation and sexual sensation have now been reported in more than 20% of men, although these studies are few and contain only a small number of patients. This limited available data support the need for further long-term studies especially focusing on the more modern techniques.

Psychological adjustment in children and adults with congenital adrenal hyperplasia

OBJECTIVE

To determine psychological health in individuals with one form of intersexuality, congenital adrenal hyperplasia (CAH), and its relation to characteristics of the disease and treatment.

STUDY DESIGN

Participants (ages 3-31 years) included 72 females and 42 males with CAH, and unaffected relatives (44 females and 69 males). Psychological adjustment was assessed with parent-reports on the Child Behavior Checklist (CBCL) and subject self-reports on the Self-Image Questionnaire for Young Adolescents (SIQYA) or the Multidimensional Personality Questionnaire (MPQ). Information about disease characteristics and genital surgery was obtained from medical records.

RESULTS

There were no significant differences between females with CAH and unaffected females on any measure. Psychological adjustment was not significantly associated with genital virilization or age at genital surgery. Males with CAH were not significantly different from unaffected males in childhood, but they showed more negative affect at older ages.

CONCLUSIONS

Psychological adjustment is not compromised in females with virilized genitalia who are treated early in life and reared as females. Adjustment does not appear to depend on the characteristics of the disease or its treatment, but sample size and restricted range limit generalizability about adjustment-disease associations.