4 Hypospadias and Epispadias Nursing Care Plans

What are Hypospadias and Epispadias?

Hypospadias and epispadias are congenital anomalies of the penis caused by incomplete development of the anterior urethra. In hypospadias, the urethral opening sits on the underside of the penis, near the tip. In epispadias, it sits on the upper surface (dorsum).

The incidence in the United States is about 3.2 in 1,000 live male births, roughly 1 in every 300 male children. The cause is unknown but tracks with genetics, low birth weight, and race or ethnic background. Chordee, an abnormal downward curvature of the penis, usually accompanies hypospadias. Other associated anomalies include undescended testes, inguinal hernia, and Wilms tumor.

The goal of repair is a straight penis with the meatus close to its normal anatomic location, done early to prevent psychological trauma. Recommended timing is 3 to 12 months of age for urethroplasty (the hypospadias or epispadias repair) and within the first year for orthoplasty (chordee repair).

Nursing Care Plans and Management

Care for a child with hypospadias or epispadias centers on improving physical appearance, supporting a positive body image, relieving pain, lowering parental anxiety, and preventing complications: bleeding, infection, catheter obstruction, and sexual dysfunction.

Nursing Problem Priorities

Hypospadias:

• Assess and manage pain
• Promote wound healing and prevent infection
• Educate on postoperative care and hygiene
• Support the child and family through surgery and recovery

Epispadias:

• Assist with preoperative prep and postoperative care
• Manage pain and discomfort
• Promote urinary continence
• Educate on bladder management and hygiene
• Support the child and family through treatment

Nursing Assessment

Assess for the following subjective and objective data:

Hypospadias:

• Urethral opening on the underside of the penis
• Ventral curvature of the penis (chordee)
• Spraying or misdirected urinary stream
• Difficulty voiding or emptying the bladder completely

Epispadias:

• Urethral opening on the top of the penis
• Wide-spaced pubic bones
• Urinary incontinence or leakage
• Difficulty voiding or emptying the bladder completely

Nursing Goals

• The child shows decreased pain, with fewer crying episodes and a normal sleep pattern.
• The child shows improved urinary elimination.
• The parent reports less anxiety.
• The child stays free from infection, with a clean, intact wound (no redness, edema, odor, or drainage) and a negative urine culture.

Nursing Interventions and Actions

1. Managing Postoperative Acute Pain

These children hurt at two points: voiding, when the misplaced meatus stings or burns, and after surgery. Stay ahead of the pain so the child rests and the repair heals.

1. Assess the location, onset, duration, frequency, and severity of the pain. Watch verbal and nonverbal cues. Guides analgesic therapy.

2. Use nonpharmacologic strategies such as distraction, relaxation, and guided imagery. Refocuses attention and eases discomfort.

3. Apply an ice compress as indicated. Relieves pain and reduces edema.

4. Administer an analgesic (such as Tylenol) as ordered. Controls pain and promotes rest.

5. Tell parents that medication prevents pain and restlessness and allows healing. Explains why the child needs the medication.

6. Keep the child in a position of comfort. Set the catheter to avoid tension and kinking. Prevents pain from pulling on the catheter.

2. Restoring Urinary Function

The misplaced meatus makes it hard to direct the stream and can cause leakage. After the catheter comes out, confirm the child can void and watch for obstruction.

1. Record I&O. Assess the stream, color, and amount on the first void and each one after. Shows the voiding pattern after the catheter is clamped or removed.

2. Assess for pain, abdominal distention, and inability to void for 8 hours after catheterization. Points to obstruction or continuing edema of the meatus.

3. Encourage high fluid intake after the catheter is removed. Offer preferred liquids hourly. Maintains hydration and free-flowing urine.

4. Support the child after catheter removal and provide privacy for voiding. Avoids embarrassment in an older child.

5. Tell parents to report any change in the urinary pattern or inability to void. Allows early intervention.

3. Preventing Infection

The wound, the catheter, and the misplaced meatus are all entry points for bacteria. Keep the site clean, keep urine flowing, and teach the family to do the same at home.

1. Assess the wound for redness, swelling, and drainage on the dressing. Flags infection or impaired healing.

2. Observe the catheter insertion site for redness, irritation, and swelling. Watch the bag for cloudy urine, foul odor, and sediment. Points to infection at the site or in the bladder.

3. Keep urine output at least 1 ml/kg/hr and report if less. A drop can mean catheter obstruction and retention, which leads to infection.

4. Obtain a urine specimen for culture and sensitivity as indicated. Identifies the organism and antibiotic sensitivity.

5. Encourage increased fluid intake for the child's age. Dilutes urine to prevent infection and, after catheter removal, encourages voiding.

6. Use sterile technique for dressing changes, catheter care, and emptying urine bags. Keeps organisms out of the wound.

7. Keep the catheter and collection bag below bladder level in a closed system free of kinks. Prevents backflow and infection.

8. Reinforce the dressing as needed. Secure the catheter to the penis with dressing and tape, and to the leg or abdomen with tape. Keeps the child comfortable and prevents catheter displacement.

9. Immobilize arms and legs with restraints, removing them periodically, and use a bed cradle after surgery. Prevents accidental removal of the catheter or contamination of the wound after repair of a severe defect.

10. Tell parents to keep the child from straddling toys, playing in a sandbox, swimming, or rough activity until the physician clears it. Prevents trauma to or dislodging of the catheter and infection.

11. Teach parents to sponge bathe the child, use loose clothing, keep feces off the wound, and cleanse after each bowel movement. Keeps the site clean without constriction.

12. Teach parents the signs of infection. They need to report them early.

13. Teach parents catheter care: irrigation, emptying the bag or using a diaper for drainage, and securing the catheter with tape. Have them demonstrate it back. The child may go home with a catheter or stent in place.

4. Reducing Anxiety

Parents fear the surgery, the appearance of the penis, and whether their son will be sexually normal. The child may fear castration or punishment. Name those fears and answer them straight.

1. Assess the source and level of anxiety and what information would relieve it. Concerns include the type of procedure, the appearance of the penis after surgery, whether it will be sexually adequate, the chance of a staged repair, and in an older child, fear of castration and a changed body image.

2. Encourage parents and child to voice concerns and ask questions about the condition, procedure, and recovery. Gives them a safe place to vent fears.

3. Encourage parents to stay with the child during hospitalization and help with care. Keeps them in the parental role.

4. Let parents make decisions about care and routines. Gives them control and keeps familiar routines.

5. Answer questions calmly and honestly. Use pictures, drawings, and models. Builds understanding and trust.

6. Explain the type and purpose of surgery, how the penis will look afterward, and the cosmetic result to expect. Tell the older child the penis will not be cut off and the surgery is not punishment. The repair lets him void standing with a directed stream, improves appearance, and preserves a sexually adequate penis.

7. Explain the cause and extent of the defect, that correction is best done between 3 to 9 months, where the meatus sits, and how many procedures it may take. Builds understanding and relieves anxiety.

8. Teach parents what postoperative care looks like: an indwelling meatal or suprapubic catheter or stents, possible restraints, and medication for pain and sedation. Sets expectations for recovery.

9. Teach parents relaxation techniques. Lowers their anxiety so they can give calm care.

10. Reassure parents and child that the defect and surgery will not compromise sexual activity or reproductive ability. Corrects the fear that comes from misinformation.