What is Hypospadias?

Most boys are born with a penis that looks normal and works well. But some boys are born with a common condition called hypospadias. Hypospadias forms a penis that not only doesn't work well but also doesn't look normal. Pediatric urologists have come up with many surgical techniques to fix this problem. The following information should help you speak to your son's urologist.

How Does the Penis Normally Work?

Male Reproductive System
Male Reproductive System
Medical Illustration Copyright © 2015 Nucleus Medical Media, All rights reserved

The main roles of the penis are to carry urine and sperm out of the body. The urethra is the tube that carries urine and sperm through the penis to the outside. The opening to the outside is called the "meatus." Both tasks are easier when the meatus is at the tip of the head ("glans") of the penis.

What is Hypospadias?

Hypospadias is a condition where the meatus isn't at the tip of the penis. Instead, the hole may be any place along the underside of the penis. The meatus (hole) is most often found near the end of the penis ("distal" position). But it may also be found from the middle of the penile shaft to the base of the penis, or even within the scrotum ("proximal" positions). Over 80% of boys with this health issue have distal hypospadias. In 15% of those cases, the penis also curves downward slightly, a condition called "chordee." When the meatus opens further down the shaft, curvature occurs in more than 50% of patients. Hypospadias is a common birth defect found in up to 1 in every 200 boys.

In most cases, hypospadias is the only developmental problem in these infants and doesn't imply there are other flaws in the urinary system or other organs.



What Causes Hypospadias?

The key steps in forming the penis take place between weeks 9 and 12 of pregnancy. During this time, male hormones tell the body to form the urethra and foreskin. Hypospadias may be caused by problems with hormones.



How is Hypospadias Diagnosed?

Hypospadias is most often noticed at birth. Not only is the meatus in the wrong place, but the foreskin is often not completely formed on its underside. This results in a "dorsal hood" that leaves the tip of the penis exposed. It's often the way the foreskin looks that calls attention to the problem. Still, some newborns have an abnormal foreskin with the meatus in the normal place. And in others a complete foreskin may hide an abnormal meatus. About 8 in 100 of boys with hypospadias also have a testicle that hasn't fully dropped into the scrotum.



How is Hypospadias Treated?

Hypospadias
Hypospadias
Image © 2003 Fairman Studios, LLC.

Hypospadias is fixed with surgery. Surgeons have been correcting hypospadias since the late 1800s. More than 200 types of operations have been described. But since the modern era of hypospadias reconstruction began in the 1980s, only a handful of techniques have been used by pediatric urologists.

The goal of any type of hypospadias surgery is to make a normal, straight penis with a urinary channel that ends at or near the tip. The operation mostly involves 4 steps:

  • straightening the shaft
  • making the urinary channel
  • positioning the meatus in the head of the penis
  • circumcising or reconstructing the foreskin

Hypospadias repair is often done in a 90-minute (for distal) to 3-hour (for proximal) same-day surgery. In some cases the repair is done in stages. These are often proximal cases with severe chordee. The pediatric urologist often wants to straighten the penis before making the urinary channel.

Surgeons prefer to do hypospadias surgery in full-term and otherwise healthy boys between the ages of 6 and 12 months. But hypospadias can be fixed in children of any age and even in adults. If the penis is small, your health care provider may suggest testosterone (male hormone) treatment before surgery.

A successful repair should last a lifetime. It will also be able to adjust as the penis grows at puberty.



What Can I Expect after Treatment for Hypospadias?

Modern hypospadias surgery results in a penis that works well and looks normal (or nearly normal). Many surgeons leave a small tube ("catheter") in the penis for a few days after surgery to keep urine from touching the fresh repair. The catheter drains into the diaper. Antibiotics are often given while the catheter is in place.

Younger boys seem to have less discomfort after repair. When the surgery is done at 6 to 12 months of age, as most pediatric urologists recommend, the child doesn't even remember it. Older boys handle this surgery well, also, especially with the types of drugs we now have to treat pain. In some cases, medication may be needed to treat bladder spasms.

Complications

The complication rate in boys with distal hypospadias repair is less than 1 in 10. Problems happen more often after a proximal correction.

The most common problem after surgery is a hole ("fistula") forming in another place on the penis. This is from a new path forming from the urethra to the skin. Scars can also form in the channel or the urethral opening. These scars can interfere with passing urine. If your child complains of urine leaking from a second hole or a slow urinary stream after hypospadias repair, he should see his pediatric urologist.

Most complications appear within the first few months after surgery. But fistulas or blocks might not be found for many years. Most problems are easily fixed with surgery after the tissues have healed from the first operation (often at least 6 months).

It's not easy to think about more surgery in these unusual cases. But there are options that offer hope for success. Unhealthy scarred tissues from prior operations can be removed and replaced with fresh tissue from another part of the body (most often from inside the cheek). This can create a working urinary channel and still look normal. If your pediatric urologist hasn't used these techniques, he/she will direct you to a center where they're used.

Check-ups after Surgery

Many pediatric urologists believe that routine office check-ups aren't needed after the first few months because the risk for problems past then is so low. Others think boys should be seen throughout childhood until after puberty. You and your son's health care provider will decide what's best.



More Information

Frequently Asked Questions

Is hypospadias passed through genes?

In about 7 out of 100 children with hypospadias, the father also had it. The chance that a second son will be born with hypospadias is about 12 out of 100. If both father and brother have hypospadias, the risk in a second boy increases to 21 out of 100.

Is it necessary to fix distal hypospadias?

Many parents ask if surgery is needed for mild forms of hypospadias. It's hard to predict problems a baby will have later in life. But there are many reasons for recommending correction, no matter how severe the condition.

  • As many as 15 out of 100 boys with hypospadias will have a penis that curves downward. When the curve is severe, when the boy is an adult it can interfere with getting an effective erection.
  • While the meatus may be in a nearly normal place, it's often deformed. Some holes are larger while others are too small. Many have a web of skin just beyond the opening. These abnormalities can affect the urine stream. Some boys will notice urine spraying to the sides or downward. Many find they need to sit to void. Voiding can cause discomfort and irritate nearby tissues. The penis works, but these problems can be embarrassing.
  • A partly formed foreskin that isn't fixed will always appear abnormal. This can call attention to the problem. Studies of boys with uncorrected hypospadias suggest lower self-esteem.

Most pediatric urologists today suggest fixing all but the most minor forms of hypospadias. In most cases, the benefits of correction far outweigh its risks.

What kind of anesthesia is used? Is it safe to put infants to sleep?

Hypospadias repair is done while the patient is asleep, under general anesthesia. Many anesthesiologists or surgeons also use nerve blocks near the penis or in the back to reduce discomfort when the child wakes up after surgery. These forms of anesthesia are very safe, especially when given by anesthesiologists who specialize in the care of children. Today, it's thought safe to do surgeries such as hypospadias repair in otherwise healthy infants.

Which repair is best for my son?

The method your son's urologist chooses will depend on a number of factors. These include the degree of hypospadias and how much the penis curves. The surgeon won't know the complete situation until the operation is under way. Surgeons who do hypospadias repair must be familiar with many techniques. Sometimes even a mild distal hypospadias may turn out to need a more complex repair. Most hypospadias repairs are done by pediatric urologists with special training and skill.

How do I care for my son's wound after surgery?

Hypospadias repair wounds don't call for special care to heal the right way. The surgeon may choose from many band age types or not use any at all. The surgeon will instruct you on care of the wound and bathing.
If your son has a catheter, it may be left to drain into diapers. Diapers can be changed as usual. If your son is older, the catheter may be connected to a bag. Your health care provider will teach you how to empty the bag. Catheters are often kept in place for 5 days to 2 weeks.

How long will the healing take?

Wound healing from hypospadias repair starts at once. But it may take many months for it to heal fully. There may be swelling and bruising early on. This gets better over a few weeks. Sometimes the skin of the penis heals with what seems like an unsightly ruffle. There may also be more obvious complications. Any recommendations for more surgery won't be made for at least 6 months, to let the tissues heal. Many slight imperfections will also resolve during this time.

If my child still has problems after many operations, can his hypospadias still be repaired?

Yes. Luckily, most operations are a success the first time. Yet, a few children need more surgery because of complications. Most of them will have good results the second time. Still, a few may have problems that lead to even more surgery. But these problems can be fixed.