Hypospadias: when the urinary opening is too low

What is hypospadias?

Normally the urinary opening is at the tip of the head of the penis. In hypospadias, the urethra does not fully form in the womb, and the urinary opening is on the underside of the penis, lower than normal: on the head of the penis, on the shaft, on the scrotum or on the perineum.

Children with hypospadias usually have three features together:

1. The urinary opening is lower down.
2. The foreskin is present only on the top side and missing on the underside. Because of this, the penis looks “born circumcised” or “half circumcised”.
3. The penis bends downward, especially during erection.

Hypospadias occurs in about one in 200–300 boys and is one of the most common congenital conditions in pediatric urology.

Types

• Distal hypospadias (about 70%): the urinary opening is on or near the head of the penis. This is the mildest and most common type.
• Hypospadias with the opening in the middle part of the penis.
• Proximal hypospadias: the urinary opening is at the base of the penis, on the scrotum or on the perineum. It often comes with marked curvature and an undescended testicle.

Sometimes the urinary opening is in the normal place, but the penis is curved. This is called “curvature without hypospadias”. More details: penile curvature.

Causes

The cause is not fully understood. Disturbances in the action of male hormones in the womb, genetic predisposition and some environmental factors play a role. It is somewhat more common when there is hypospadias in the family and in children conceived with assisted reproductive technologies.

The most important rule: do not circumcise

A child with hypospadias should not be circumcised. In the repair operation, the foreskin is used to cover the new urethra and to provide skin for the penis. In a child with hypospadias, circumcision can be done only together with the repair operation.

Treatment

Treatment is surgical. The best time is 6–18 months of age: the child will not remember the operation, and the tissues are developed enough.

The goals of surgery:

• to straighten the penis,
• to bring the urinary opening to the tip of the head of the penis,
• to give the penis a normal appearance,
• to allow the child to urinate standing up, with a straight stream.

Distal hypospadias is corrected with a single operation in most cases. In severe proximal hypospadias and marked curvature, surgery may be done in two stages. More details: hypospadias repair.

Results and follow-up

In distal hypospadias the results are very good; the complication risk is about 5–10%. In proximal cases the risk is higher. The most common complications: a small hole (fistula), narrowing of the urinary opening, widening of the new channel. Most are corrected with a second, minor operation.

Children who have had surgery are followed until toilet training is complete and, if possible, until adolescence.