Impact of Pre-Operative Instructions Regarding Hypospadias Repair on Mothers’ Knowledge, Practices and Selected Post-Operative Outcomes

Introduction

 Hypospadias is a developmental anomaly characterized by a urethral meatus that opens onto the ventral surface of the penis proximal to the end of the glans, the meatus may be located anywhere along the shaft of the penis from the glans to the perineum (Roychoudhury, 2019).This leads to arrest in standard growth of the penile urethra, foreskin, and penile ventral aspect, and cause different abnormalities, the urethral opening can be presented anywhere along the penis ventral shaft, within the scrotum, or even in the perineum. And also, hypospadias is associated with a ventral curvature of the penis, or chordee (Hassouna, et al., 2020).

Hypospadias is one of the most common congenital anomalies with an incidence reported to be 1 in 300 males (0.3%), the recurrence rate is approximately 13 times greater in first degree relatives including brother, father, or son .Both genetic and environmental factors have been associated with hypospadias, the severity of hypospadias is based on the position of the urethral opening and the degree of ventral curvature of the penis (Hockenberry & Wilson, 2018).

Presentation of hypospadias is variable, ranging from mild forms with the meatus located at the corona (distal) to severe forms with the meatus in the perineum (proximal) (Gong & Cheng, 2017) . A more recent classification indicates the site of urethral meatus which divided into distal penile hypospadias 75%, proximal hypospadias 15%, and glanular 10%, and also the site of the urethral meatus may be before and after chordee correction, the prepuce (incomplete or complete), the glans (cleft, incomplete cleft or flat), the width of urethral plate, the degree of penile rotation if present and the presence of scrotal transposition (Hadidi, 2017).  

 Causes of hypospadias remain unknown, several ways have been explored to explain this congenital defect of the genital organ, one of these factors include endocrine disorders such as insufficient secretion of androgens or insufficient response by the target tissues, and also there are several causes of hypospadias such as  genetic disorders may be found in several members of the same family, young and old age of mothers, low-birth-weight babies and twins, placental insufficiency, environmental factors such as estrogen like molecules, pesticides, and fertilizers (Renaux, et al ., 2019).

The choice of surgical procedure is affected primarily by the severity of the defect and the presence of associated anomalies .The preferred time for surgical repair is 6 to 12 months of age, before the child has developed body image. The principal objectives of surgical correction are, to enhance the child’s ability to void in the standing position with a straight stream, improve the physical appearance of the genitalia for psychological reasons, and to preserve asexually adequate organ (Lisa, et al., 2019). Repair is challenging owing to the variable anatomy and quality of the urethral plate. Those children with fibrotic and deficient urethral plates often require staged repair with urethral plate augmentation with preputial or buccal tissue (Gong & Cheng, 2017).

Complications occur in 10% of cases, include urethrocutaneous fistula which is the most common complication, the principles of its repair are to rule out distal obstruction and perform multi-layer repair with a fascial layer interposed to prevent overlapping suture lines. Another complication is excess penile skin which needs excision for adequate cosmesis, it is removed at least 6 months post-operatively to let the wounds fully recover, the stricture of the neo –urethra, urethral diverticulum, persistent chordee are considered rare complication, but if present repair may be delayed until after adolescence .Which is the time of the penis to stop growing (John, etal., 2020).

 Pediatric nurse has very important role in  monitoring vital signs , encourage fluid intake to maintain adequate urine output, maintain patency of stent , monitor intake and output , observe the urine for cloudiness or a foul odor, and  notify the pediatric surgeon if there is any abnormality , instruct  the parents in the care of child who has stent or urinary diversion to avoid giving the child a tub bath until the stent is removed and the importance of  follow up for dressing removal after surgery ( Linda& Angela , 2019 ) .

Significance of the study

Hypospadias is one of the commonest conditions seen in pediatric urology practice, genetic and environmental factors play a significant role in its etiology. There is a wide variation in the prevalence reported from a variety of studies however most report between 5 and 50 per 10,000 live births , most are diagnosed at birth and some when circumcision is attempted( Springer ,etal. ,2016).

The incidence of meatal abnormalities associated with hypospadias varies from 9.6% to 31%.The meatal stenosis is the most common, affecting 9.1– 16.7% of children (Pan, 2019).Congenital anomalies are estimated to be the fifth leading cause of death in fewer than 5 year old globally. And also it can affect an estimated 1 in 33 infants, resulting in 3.2 million children with disabilities related to birth defects every year (WHO, 2019).

Post-operative nursing care of hypospadias repair is directed toward preventing infection and instructing parents in home care of the child, including pain control, cleansing the operative site of stool and urine, observation of the wound for complications and activity restriction are discussed, the child should avoid vigorous sports activities and use of toys that are straddled for 2 weeks postoperatively (Hockenberry & Wilson, 2018).Parental especially mothers involvement in quality of care related to hypospadias repair is very important. It is proved that the child recover earlier when the parents involved in care. Mothers need information about the admission, the procedure itself, possible complications, and both the short and long-term surgical outcomes within individual units (Mohamed, 2019).

There are a few studies in urogenital system disorders especially hypospadias  in Egypt,  when reviewed the registration office in Minia university hospital for obstetric and pediatric I found  that the number of children with hypospadias was 100 cases in- the last year 2019, this number is large among other types of congenital anomalies , as well as the mothers have  lack of  knowledge and practices about care of child with hypospadias  repair which may lead to post-operative complications for a child , for these  reasons, this study will be designed to improve mothers’ knowledge and practices about  care of  child with hypospadias repair  and prevent  post- operative complications.

Aims of the Study

 The aim of the current study was to evaluate the impact of pre-operative instructions regarding   hypospadias repair on mothers’ knowledge, practices and selected postoperative outcomes.

Research hypotheses

• Mothers of children with hypospadias who will receive pre-operative instructions about hypospadias repair will have better knowledge and practice than mothers in the control group.
• Children of mothers who will receive the pre-operative instructions will have less post-operative complications than children in the control group.

Subjects &Methods

Research Design:

Quasi-experimental research design (pre-posttest) was used in the current study. .Quasi-experimental research design examines whether there is a causal relationship between small independent and dependent variables. It involves the manipulation of an independent variable without the random assignment of participants to conditions or orders of conditions (Grove & Gray, 2018).

Setting:                                                                             

The current study was conducted at in-patient surgery unit at Minia university hospital for obstetric and pediatrics, which located in Minia city. It serves Minia governorate and affiliated to Minia University, it received about 200 children annually. The in-patient surgery unit composed of one floor, and the floor consisted of two rooms, each room includes eight beds, In-patient surgery unit provide the children with many services like treatment, surgical operations, laboratory investigations, and outpatient follow-up.

Subjects:

 A purposeful sample of 100 mothers of children with hypospadias was participated in the study. The sample divided into two equal groups: 50 for (study group) those mothers of children with hypospadias who were exposed to pre-operative instructions and 50 for (control group) those mothers of children with hypospadias who were exposed to routine hospital care.

Inclusion criteria:

• Children who have one stage surgical repair of hypospadias.
• Children aged from 6 months to 4 years.
• Mother should be the primary caregiver that accompanied with the child in the hospital.
• Pre & post-operative child.

Exclusion criteria:

• Children with recurrent hypospadias.

Data collection tools:

Three tools were used for both control and study group and included the following:

Tool (I):- A structured interview questionnaire, it was designed by the researcher after extensive review of related recent literature.It composed of these parts:

Part (I):(A)- Sociodemographic characteristics of mothers such as, age, level of education , place of residence , presence of consanguinity, degree of consanguinity.

Part (I):(B)- Bio-demographic data related to the child affected with hypospadias such as age, family history of hypospadias, history of circumcision.

Part (II):  It included questions related to mothers’ knowledge about hypospadias and consisted of 33 questions, adapted from (Mohamed,2019), and some modification is done by researcher , it includes (definition of hypospadias , signs &symptoms of hypospadias , signs and symptoms of wound infection , post-operative care (time of discharge from hospital , time of removing of surgical dressing , care of the urinary stent ,double diapering technique, diet , hygiene ,medications , activity of child ,when to call the doctor) .

Knowledge scoring system: - The score 1 was given for (correct answer), and zero for (incorrect answer) or (I don’t know) and total knowledge score of less than 50% considered as unsatisfactory, while score of 50% and more considered as satisfactory.

Tool (II): Observational checklist about diaper care, it included (14 items) to evaluate mother's practice adopted from (Mohamed, 2019).

Practice scoring system: - Done practice scored as 1, and not done practice scored as zero. The level of practices is classified as total practice score of less than 50% considered as unsatisfactory, while score of 50% and more considered as satisfactory.

Tool (III):- Post-operative outcomes assessment record adopted from (Soheir, etal., 2018) for the purpose of follow-up of all children (study and control group) starting from the first day post-operative until one month post-operatively.

The recording sheet was divided into three sections:

• At the first postoperative day (immediate):to evaluate early complications such as bleeding and fever
• At the 7^th day after surgical repair (at the time first dressing removal) to evaluate early complications such as wound infection, bruising, graft necrosis, wound dehiscence, urinary obstruction, burning on urination and falling of the urinary catheter .
• At  1^st  month of surgical repair, three items was evaluated;
  • The first is late complications such as fistula, meatal stenosis, and urethral obstruction.
  • The second one is the post-operative functional outcome through assessing the stream of urination (one direction or interrupted).
  • The third one is cosmetic appearance by assessing the children' penis postoperatively and comparing its appearance with normal appearance of penis made by assessing shape of glans, shape of meatus and shape of penile skin and straight penile axis.

Validity and Reliability of the Tools

 The content validity of the tool was performed by a jury of 5 experts in the field of pediatric nursing and pediatric surgery. Tools were examined for content coverage, clarity, relevance, applicability, wording, length, format, and overall appearance. Based on experts` comments and recommendations modifications were made. The internal consistency was measured to detect the extent to which the items of the tools measure the same concept and correlate with each other. Cronbach's alpha coefficient was used to assess the internal consistency of the tools were .0.835 & 0.872, respectively.

Pilot study                                              

The pilot study was conducted on 10% (10 mothers) who met the inclusion criteria, was done to ensure the feasibility, objectivity, applicability, clarity, adequacy, content validity, and internal consistency of the study tools and to determine possible problems in the methodological approach or the tools. The results of the pilot study were used to test the proposed statistical and data analysis methods. The tools were completed without difficulty, adding support to the validity of the tools, little modification was done, e.g., rephrasing and rearrangements of some sentences. The time required for completion of the interview questionnaire didn't exceed 30 minutes. Mothers involved in the pilot study were included in main study sample.

Data collection procedure

Administrative approval was obtained from the Dean of Faculty of Nursing, Minia University to the manager of hospital before implementation of the study. An objective of the study was explained to the manager to gain cooperation and to allow meeting with the mothers. The time of data collection is 6 months from beginning of October to the end of March 2020-2021 .The researcher was introduced herself to children' mothers at the day of surgical operations, was wearing protective mask and follow appropriate distance when interviewing mothers . All protective procedures were taken during interviewing mothers.

An oral consent was taken from each mother after complete description of the purpose and nature of the study then the researcher was filled the questionnaire sheet from mothers to collect the personal data about mothers and their children in both study and control groups, then all mothers were exposed to the pre-test sheet tool (1) ,tool (2) ,after that the prepared pre-operative  instructions was explained to the mothers in the study group at the day of operation through four educational sessions each session took about 20-30 minutes on individual  basis and sometimes for a group of mothers ranged  from 2 to 4 mothers.

Arabic illustrated pre-operative instructions about appropriate post-operative care for the child after surgical repair of hypospadias was prepared by the researcher and it was given and explained to the mothers in the study group. It included simple instructions about (dressing, care of urinary stent, diaper care, prevention of urinary obstruction, medications, hygienic care, diet, fluid intake and activities, and when to call the doctor). To facilitate understanding, an instructional illustrated Arabic booklet and re-demonstration of practice on a doll was done.

                At the first day after surgical correction and at   the 7^th day which is the first time of dressing removal, the researcher observed and recorded the early post-operative complication as mentioned in tool (III). The late post-operative complication, the functional and cosmetic outcomes was observed and recorded through post-operative outcome assessment record (by 1^stmonth after surgical operation). Mothers' knowledge and their practices were evaluated at 1st week after surgical operation, post/test was done at 1^st week after surgical repair for the mothers’to evaluate the effect of preoperative instructions.

Ethical Consideration

A written initial approval was obtained from the research ethical committee of the faculty of nursing, Minia University. Oral informed consent was obtained from the mothers who participated in this study. Each assessment sheet was coded and mother's name was not appear on the sheets for the purpose of anonymity and confidentiality, The researcher explained the purpose and nature of the study through direct personal communication before starting their participation in the study. These data were confidential and were used for the research only. The study followed the common ethical consideration to participate in clinical research, and privacy was assured during data collection. Anonymity and privacy were assured through coding the data, and mother has the right to refuse participation in the study without any rationale. The researcher also informed the mothers about their rights to withdraw from the study at any time without giving any reason and without any effect on the care of their children.

Results

Table (1): Comparison between the Study and Control Group of Mothers regarding their Socio-Demographic Characteristics (n= 100).

NS= Not statistically significant differences

 Table (1) : It was found that 82% of mothers’age in the study group ranged  between 20-30 years old and while the age of 78% of the mothers in the control group ranged between 20-30 years old and the mean of their ages was 28.3 ± 9.2 and 27.9± 5.1, respectively . Regarding to mothers level of education it was found that 36% of  the mothers in the study group have secondary school otherwise 42% of  mothers in the control group did not read or write. The same table revealed that the majority of mothers  in study group and control group (84 % , 98%); respectively came from urban area. In addition,  80% of mothers in the study group and 64% in control group had 1-3 children.

Figure (1) Percentage Distribution of Consanguineous Marriage among Parents

Figure (1) Illustrated  that more than one third and more than two fifths of the study and control groups (36% and 44%); respectively have consanguineous marriage, however a relatively high percentage of non- consanguineous marriage in study and control groups (64% and 56%); respectively.

Table (2):  Comparison between Study and Control Groups of Children regarding their demographic Characteristics (n= 100).

NS= Not statistically significant differences

Table (2): Showed that 32% of children in the study group their ages ranged between 1-< 2yrs while 28% of children in the control group their ages ranged 1year- < 2yrs with  mean age ±SD, 4.5± 10.1and 3.5 ± 16.3 respectively. In addition, 88% of children in the study group and 82% in the control group had no family history of hypospadias. Meanwhile, 94% of children in the study group and 92% in control group didn’t have been circumcised before hypospadias repair, with no statistically significance differences between the study and control groups.

Table (3): Comparison between the Total Level of Mothers’ Knowledge at Pre and Post- Test Program in Study and Control Group (n=100)

NS= Not statistically significant differences ** statistically significant difference at < 0.01

It was clear from (table 3) that ,98% of mothers in the study group, compared to 100% in the control group have un satisfactory level of knowledge in pretest, while in posttest 94% of mothers in the study group compared to 6%  in control group  have satisfactory level of knowledge with statistically significance difference P-value at  0.001.

Table (4): Comparison between the Total Score of Mothers’ Practice at Pre and Post- Test Program in Study and Control Group (n=100)

NS= Not statistically significant differences

Table (4): cleared that 78% of mothers in the study group compared to 82% in the control group have un satisfactory level of practice in pretest. On the other hand 100% of mothers in the study and control group have satisfactory level of practice in post /test.

Table (5):  Comparison between Study and Control Group regarding Post- Operative Outcomes at First day and 1^st week (n= 100).

NS= Not statistically significant differences  ** statistically significant difference at < 0.01

Table (5):- The above table reveals that 92%and 90% of children in the study and control group respectively have no bleeding in first day post-operative. As well as 92% of children in the study group, compared to 80% in the control group have no fever in the first day post -operative. While in the 1^st week post-operative 94% of children in the study group, compared to 88% in the control group haven’t expose expose to wound infection. Furthermore 100% of children in the study group and 98% in the control group did not expose to post -operative wound bruising, while (96% and 94%); respectively did not expose to wound dehiscence. On addition, the vast majority of children in the study group and control group (90%, 80% respectively) did not expose to urinary obstruction. Wherever 96% of children in both groups did not expose to graft necrosis with no statistically significance differences. On the other hand, the minority of children in the study group and control group (6%, 22% respectively) did not have been exposed to burning sensation during urination or urinary catheter fall with statistically significance difference P. value at 0.02.

Figure (2): Post- Operative Complications at 1^st month

 Figure (2): It was clear from figure 2 that the minority of children in the study and control group (8% versus 12% respectively) suffer fromfistula at 1^st month post-operative with no statistically significant differences. While, 8% versus 12% respectively, suffer from meatal stenosis   with no statistically significant differences.

Figure (3): Post- Operative Functional and cosmetic outcomes.

Figure (3):  Cleared that,92% compared to 88% of children in the study and control group respectively had one direction of urine stream, while 84% and 80% respectively had normal cosmetic appearance and 80% of children in both groups had normal shape of glans. Furthermore, 90% of children in the both groups had normal shape of meatus. In addition, 78% of children in the study group had normal shape of penile skin, versus 72% in the control group with no statistically significant differences.