Hypospadias

Hypospadias is a congenital difference in the development of the urethra and penis in which the urinary opening is positioned below its normal location at the tip.

The severity varies according to the location of the opening.

Cases can broadly involve:

• An opening near the head of the penis.
• An opening along the penile shaft.
• An opening near the base of the penis or penoscrotal region.

The position of the meatus alone does not determine how complex the condition is.

The surgeon also considers penile curvature, the shape of the glans, the urethral plate and the tissues available for reconstruction.

Some very mild forms that do not interfere with urination or penile function may not require surgery. This decision is made after specialist assessment.

Parents or clinicians may notice one or more of the following:

• The urethral opening is below the normal position.
• Urine sprays or travels in an unusual direction.
• The penis curves downward.
• The foreskin forms a hood over the upper surface of the glans and is incomplete underneath.
• The shape of the glans appears different.

Hypospadias is usually identified during examination after birth.

When severe hypospadias occurs together with one or both testicles being non-palpable or absent from the scrotum, further specialist assessment may be required to evaluate genital development more broadly.

Diagnosis is primarily based on physical examination.

The clinician assesses:

• The position of the urethral opening.
• Glans anatomy.
• Distribution of the foreskin.
• Presence and degree of penile curvature.
• Penile size and available tissues.
• Whether both testicles are present in the scrotum.
• Any associated congenital abnormalities.

Isolated hypospadias usually does not require imaging simply to confirm the diagnosis.

Children with severe forms or additional abnormalities may require further investigations according to the findings and specialist assessment.

Treatment:

Treatment depends on the severity of hypospadias and its expected effect on urination, penile function and appearance.

Some very mild forms may not require surgery when the urethral opening is close to the normal position and there is no significant functional problem or curvature.

When surgical repair is required, the goals are to:

• Correct significant penile curvature when present.
• Reconstruct an appropriately sized urethral channel.
• Bring the urinary opening toward the normal position at the glans.
• Achieve good urinary function.
• Reconstruct appropriate glans and penile skin coverage.

Several surgical techniques are available and no single operation is appropriate for every child.

The surgical approach depends on:

• Location of the urethral opening.
• Degree of penile curvature.
• Urethral plate anatomy.
• Glans anatomy.
• Tissue available for reconstruction.

Primary repair is commonly performed between 6 and 18 months of age when surgery is indicated.

Many cases can be repaired in a single operation, while more complex forms may require staged reconstruction.

Why Circumcision Should Wait:

If hypospadias is present or suspected, routine circumcision should not be performed before specialist assessment.

Foreskin tissue may be useful during reconstruction of the urethra in some cases.

Preserving the foreskin until the child has been assessed therefore gives the surgeon the full range of reconstructive options.

Parents who notice an abnormal position of the urinary opening or an unusual penile appearance should seek specialist assessment before circumcision.

Before hypospadias repair, the surgeon evaluates the anatomy and severity of the condition and develops an individual reconstructive plan.

Parents should follow the medical team's instructions regarding fasting and medications before anesthesia.

The medical team should be informed if the child:

• Takes regular medication.
• Has medication allergies.
• Has a known bleeding disorder.
• Develops fever, infection or a new illness before surgery.
• Has another medical condition that may affect anesthesia or surgery.

Before the procedure, parents may discuss:

• The severity of the hypospadias.
• Whether penile curvature is present.
• The proposed surgical technique.
• Whether repair is expected to require one or more stages.
• Whether a urinary catheter or stent will be used.
• Wound care.
• Follow-up after surgery.

After hypospadias repair, parents receive instructions regarding wound care, medication and activity.

A small urinary catheter or stent may be left temporarily after some types of repair, depending on the surgical technique.

Some swelling, bruising or discomfort around the surgical area may occur during the early recovery period.

Parents should follow instructions regarding:

• Dressing and wound care.
• Care of the catheter or stent if present.
• Medication and pain relief.
• Bathing.
• Diaper care.
• Activities that should temporarily be avoided.

The medical team should be contacted if the child develops:

• Persistent or increasing bleeding.
• A significant fever.
• Increasing redness or swelling.
• Abnormal wound discharge.
• Severe or worsening pain despite prescribed treatment.
• Failure of urine to drain through the catheter when one is present.
• Significant difficulty urinating after catheter removal.

Follow-up is important because some complications of hypospadias repair may not become apparent immediately.

Problems monitored during follow-up can include:

• A urethrocutaneous fistula causing urine to leak through an abnormal opening.
• Narrowing of the urethral opening or reconstructed urethra.
• Breakdown of part of the repair.
• Persistent or recurrent penile curvature.
• Changes in the direction or strength of the urinary stream.

Assessment later in childhood, after toilet training and sometimes around puberty may be useful to ensure that urinary and penile function remain satisfactory as the child grows.